STATEMENT Thomas J. Magnani D.D.S. Telephone: FY Alvin Grayson D.D.S. 7 West 51st Street Hf paying by credit card, enter the amount you are paying in the remittance box and 7th Floor Moa below New York NY 10019 = —— Exp Ose ___ Jeff Epstein 9 East 71st Street New York NY 10021 [Date [Account 6/29/2016 P| IMPORTANT - PLEASE DETACH UPPER PORTION AND RETURN WITH YOUR REMITTANCE TO INSURE CREDIT TO PROPER ACCOUNT [Dae [Patent | Deeerpton + Charges Create | Saonco 5/26/2016 Previous Balance 6/7/2016 | Jeff Recall Oral Exam 40.00 6/7/2016 | Jeff Adult Scale & Prophy 180.00 Fluorid 12.00 Account Total 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 Thomas J. Magnani D.0.S. Alvin Grayson D.0.S. 7 West 5istStreet 7th Floor New York NY 10019 EFTA00316253