STATEMENT Thomas J. Magnani D.D.S. Telephone: r Alvin Grayson D.D.S. 7 West 51st Street 7th Floor New York NY 10019 I paying by credit card, enter the amount you are paying in the remittance box and fil out below. Mastercard Visa Amex Card# Signet Mr. Jeff Epstein 9 East 71st Street New York NY 10021 6/29/2016 Previous Balance 0,00 7/20/2016 1 Periapical X Ray ; 30.00 7/20/2016 Amalgam 2 Surface Perm. ‘ 405.00 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.D.S. Alvin Grayson D.D.S. 7West51stStreet 7th Floor New York NY 10019 EFTA00316267