STATEMENT Telephone: Thomas J. Mai ff paying by credil card, enier the amount you are paying inthe fermt@ance box and tt oul Below, ~ Mastercard —_. Visa _. Amex Card # — Exp Date Sgnatwe Si Cte Jeff Epstein ~ Date Account 301 East 66th Street 12/29/2011 3114 Apt #10 f Remittance | New York NY 10065 — IMPORTANT - PLEASE DETACH UPPER PORTION AND RETURN WITH YOUR REMITTANCE TO INSURE CREDIT TO PROPER ACCOUNT Date | Patient Description | Charges Credits Balance f ‘voor | Previous Balance 0.00 ff 12/14/2011 \ Recall Oral Exam 40.00 40.00 | 12/14/2014 | Jeff | Adult Scale & Prophy 180.00 220.00 12/15/2014 | Jeff / Ins Form submitted - Aetna \ 7 Account Total 220.00 if payment has been sent, please disregard this statement - Thank You. We accept credit cards! You may complete ha 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 Grayson i i i EFTA00312738