Thomas J. Magnani Alvin Grayson Jeff Epstein 301 East 66th Street Apt #10f New York NY 10065 STATEMENT Telephone: # paying by credit card enter the amount you are pay: Ml out below ] wg in the remittance box and | Mastercard — View . amon Card # ——— — Exp Date 7 | Sognatee Sig Code Date Account 9/28/2011 =| ti2CS™S eee Remittance IMPORTANT « PLEASE DETACH UPPER PORTION AND RETURN WITH YOUR REMITTANCE TO INSURE CREDIT TO PROPER ACCOUNT ‘Date Patient Description Charges : Credits Balance | 8/31/2011 Previous Balance 197.00 8/31/2011 | Jeff MASTER CARD | 197.00 0.00 9/12/2011 | Jeff Recall Oral Exam 40.00 40.00 9/12/2011 | Jeff | Adult Scale & Prophy 180.00 220.00 | Account Total 220.00 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 90 Days 120+ Days 220.00 0.00 | 0.00 0.00 0.00 Thomas J, Magnani Alvin Groyson I I i i Sy EFTA00312737