STATEMENT OF ACCOUNT Thomas J. Magnani, D.D.S. 7W51 DENTAL GROUP 7 W 51st Street, Floor 7 New York, NY 10019 GUARANTOR NAME AND MAILING ADDRESS Mr Jeff Epstein 9 East 71st Street New York, NY 10021 CHART NO. PAGE NO. 1 BILLING DATE 10/26/2017 DUE DATE 11/25/2017 CREDIT CARD # EXP. NAME (AS it sweats al care) SIGNATURE TYPE OF CARD EA LTIDUNT ENCLOSED SECURITY CODE I $ TO ENSURE PROPER CREDIT, PLEASE DETACH AND RETURN THIS PORTION OF THE STATEMENT WITH YOUR PAYMENT PLEASE RETAIN THIS PORTION OF THE STATEMENT FOR YOUR RECORDS DATE DESCRIPTION PATIENTS NAME CHARGES CREDITS 09/15/2017 Balance Forward 0.00 09/19/2017 Prophylaxis-adult Jeff 180.00 09/19/2017 Periodic oral evaluation Jeff 40.00 09/26/2017 Office Visit Jeff 0.00 09/28/2017 Crown-porcelain/ceramic substr Jeff 2400.00 09/28/2017 Permanent Cement Jeff 0.00 09/28/2017 Office Visit Jeff 0.00 10/03/2017 AMEX Payment - Thank You Jeff -220.00 CURRENT BALANCE OVER 30 DAYS OVER 60 DAYS OVER 90 DAYS TOTAL BALANCE 2400.00 0.00 0.00 0 00 2400.00 Make checks payable to: Thomas J. Magnam. DDS. To pay by Credit Card. please call our office ME= 01987-2012 Henry Schein, Inc. ThomarThignani. D.D.S. - 7W51 DENTAL GROUP 7 W 51st Street, Floor 7 New York, NY 1031 EFTA00292242