3/27/2014 3/28/2014 3/28/2014 4/2/2014 4/2/2014 Thomas J. Magnani D.D.S. Alvin Grayson D.D.S. Mr. Jeff Epstein Y PO Box 806 Lf “ae New York NY 10150 STATEMENT Telephone: if paying by ered card, ener the emount you are paying in the remitiance box end 1 out below ____ Masiercard Vee Amex Cace Exp Owte | Signatuco — — Sig Code Date Account E _4/30/2014 —_ 6 CoE Remittance IMPORTANT - PLEASE DETACH UPPER PORTION AND RETURN WITH YOUR REMITTANCE TO INSURE CREDIT TO PROPER ACCOUNT Previous Balance Recall Oral Exam Adult Scale & Prophy Comp. W. Etch 1 Surface Comp. W. Etch 1 Surface Account Total If payment has been sent, please disregard this statement - Thank You. We accept credit cards! You may complete and return the top part of this statement, or call the office at Current | 30 Days 60 Days 420+ Days | 90 Days - 0.00 920.00 | 0.00 0.00 0.00 Thomas J. MagnaniD.0.S. AlvinGraysonD.D.S 7 West 51st Street 7th Floor New York NY 10019 | EFTA00311291