Thomas J. Magnani D.D.S. Alvin Grayson D.D.S. STATEMENT Telephone 7 West 51st Street MW paying by credit card, enter the amount you are paying in the remittance box and 7th Floor fit out _ se _ New York NY 10019 ~~ —_ Cardé = Exp Date = Signature — — Sig Code | ~ Date Account — —_ 11/27/2013 9648 OO — Remittance = IMPORTANT - PLEASE DETACH UPPER PORTION AND RETURN WITH YOUR REMITTANCE TO INSURE CREDIT TO PROPER ACCOUNT Date Patient Description L Charges Credits Balance 10/31/2013 Previous Balance 220.00 fu (C18 tpl. for | clecarné “J | Account Total 220.00 You have probably overlooked this statement. Your remittance would be appreciated. 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 0.00 220.00 0.00 | 0.00 | 0.00 Thomas J. MagnaniD.D.S. AlvinGraysonD.0.S. 7 West 51st Street 7th Floor New York NY 10019 | EFTA00313297