STATEMENT Thomas J. Magnani D.D.S. Telephone: Alvin Grayson D.D.S. 7 West 51st Street It paying by credit card, enter the amount you are paying in the remittance box and 7th Floor enna ret i Mastercard Visa Amex New York NY 10019 _ — — Card# Signature Mr. Jeff J Epstein 9 East 71st Street New York NY 10021 [Date Account B7B1/2076 [Remittance | IMPORTANT - PLEASE DETACH UPPER PORTION AND RETURN WITH YOUR REMITTANCE TO INSURE CREDIT TO PROPER ACCOUNT [aie | Palont [___Descipion | Ghose | Crodis | folonoe 7/28/2016 Previous Balance 2,880.00 7/28/2016 Comp. W. Etch 1 Surface 3,305.00 7/28/2016 Comp. W. Etch 1 Surface 3,730.00 7/28/2016 Comp. W. Etch 1 Surface 4,155.00 7/28/2016 Comp. W. Etch 1 Surface 4,580.00 7/28/2016 7/28/2016 8/11/2016 Ortho treatment adult Cement Crown AMERICAN EXPRESS 12,080.00 12,080.00 9,200.00 Account Total 9,200.00 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 at Thomas J. MagnaniD.0.S. Alvin Grayson D.D.S. 7 West5istStreet 7th Floor New York NY 10019 | | EFTA00316284