FEB-13-2033 10:36 FPCM:CR.MAGNANI 21e f'difirdtl TO:16467067223 P.3/3 Thomas J. Ma I A18. Alvin Grayson k leff Epstein Box 806 York NY 10150 a ( I HISTORICAL STATEMENT Date Pedant 0sticrIption 1/22/2014 1/28/2014 1/26/2014 Ju. (t•o. Julia Julia Julia Bleaching Trays Recall Oral Exam Adult Scaled Prophy II a... 5—t.4 pc.44.4 Cunent 30 Days 60 Day1 1/1/2014 to 2112/2014 [Julia] Tolaphono: (212) 555-1090 Date Account 2/12/2014 10348 Charges Credits Balance 950.00 960.00 40.00 990.00 180.00 1,170.00 Account Total 1,170.00 Patiant Charges 1,170.00 Patient Payments 0.00 Patient Credits 0.00 Patient Debits 0.00 90 Days 120+ Days Than J. Wenn IM NAM Growl... 7 West 51st IP. pet 701 Floor New York NY 10019 (212) 699-1003 EFTA00590001