STATEMENT [ if paying by credit card, enter the amount you are paying in the remittance box and below. Thomas J. Magnani | fil out __ Mastercard ___ Visa Agmax Carc# Exp Date |_Stonature Sag Code r_ Jeff Epstein [_ Date | Account Box 806 RYO §/9/2013 10345 New York NY 10150 ” Remittance IMPORTANT - PLEASE DETACH UPPER PORTION ANO RETURN WITH YOUR REMITTANCE TO INSURE CREDIT TO PROPER ACCOUNT Date : Patient Description ] Charges | Credits Balance _— + + + +——— | 3/28/2013 Previous Balance 332.00 | 4/4/2013 | Julia Laser Bleaching 750.00 1,082.00 4/17/2013 | Julia VISA | 332.00 750.00 Account Total 750.00 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 a Current 30 Days | 60 Days 90 Days 120+ Days _ — 4 ~ 750.00 | 0.00 0.00 0.00 0.00 — ™ “ ™ Pe EFTA00313133