STATEMENT tf paying by credit card, enter the amount you are paying in the remittance box and Thomas J. Mai Alvin Grayson fil out below. Mastercard — Visa Amex | Carc# . . Exp Date | Signature . _ 7 — Sig Code __ Mr. Jeff Epstein ; . ; Date Account| 301 East 66th Street N\tirl Ahiny 5/9/2013 9293 Apt 3 10F a J — . Remittance _—i| 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 3/28/2013 Previous Balance 0.00 4/2/2013 | Svetileana Recall Oral Exam 40.00 40.00 4/2/2013 | Svetleana Adult Scale & Prophy 180.00 220.00 4/2/2013 | Svetieana Bleach Touch-Up Kit 65.00 285.00 | Account Total 285.00 If payment has been sent, please disregard this statement - Thank You. We accept credit cards! You may complete and r p part of this statement, or call the office at Current | 30 Days | 60 Days 90 Days | 120+ Days 285.00 0.00 0.00 | 0.00 0.00 Thomas J: Magnani = Aun Grayson = PO EFTA00313134