EFTA00313134.pdf

STATEMENT Thomas J. Ma . Telephone: Alvin Grayson IM MO bY COON cad. Oftlit the Sniourd you we ming n Ire in CS OCCC ells Out below Mastercard Asa Amex Card• E,p OM. WAIN Sig COOS /Mr. Jeff Epstein Date Account / 301 East 66th Street 5/9/2013 9293 I Apt 3 1OF Remittance ' New York NY 10065 impoR, ;4,4 MINN OfThtli UPPER PORTION AND RETURN WITH YOUR REMITTANCE TO INSURE CREDIT TO PROPER ACCOUNT 77:late Patient Description Charges Credits Balance 3/28/2013 Previous Balance 0.00 4/2/2013 Svetleana Recall Oral Exam 40.00 40.00 4/2/2013 Svetleana Adult Scale & Prophy 180.00 220.00 4/2/2013 Svetleana Bleach Touch-Up Kit 65.00 285.00 Account Total 285.00 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 Current 30 Days 60 Days 90 Days 120+ Days 285.00 0.00 0.00 0.00 0.00 Thomas J. Magnani Alvin Grayson M. EFTA00313134