STATEMENT Thomas J. Magnani D.D.S. Alvin Grayson D.D.S. 7 West 51st Street 7th Floor New York NY 10019 Jeff Epstein 9 East 71st Street New York NY 10021 Telephone: (212) 688-1090 I pry,.; by creed Geed enle, the irrounl rai va c-reriC mw. sni • MA talow. Vlia Ar Ca Cans s Ero Dale Strout sccxw Date Avows 11/26/2014 I: 3114 Remittance IMPORTANT - PLEASE DETACH UPPER PORTON NC RETURN Van YOUR REMITTANCE TO INSURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 10/30/2014 11/21/2014 11/21/2014 Jeff Jeff Previous Balance Recall Oral Exam Adult Scale & Prophy %II petty. 40.00 180.00 kimip A et&kit ntaar.- loiticipi{ 0.00 40.00 220.00 Account Total 220.00 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 212-688-1090. Current 30 Days 60 Days 90 Days 120+ Days 220.00 0.00 0.00 0.00 0.00 Thomas J. laegnanl D.D.S. AMn Grayson D.O.S. 7 West 5151 Street 7th Floor New York NY 10019 (212) 686-1090 EFTA01122953