EFTA00312738.pdf

STATEMENT Thomas J. Ma . Telephone: II paying by credal card. eaten amoral you ate Piaci in the can bile itC Id col Slaw Mastartard 4Ssa Amex Cams by Or Swaim Sq Coda Jeff Epstein Date Account 301 East 66th Street 12/29/2011 3114 Apt # 10 f Remittance New York NY 10065 IMPORTANT- PLEASE DETACH UPPER PORTION AND RETURN WITH YOUR REMITTANCE TO INSURE CREDIT TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 11/30/2011 Previous Balance 0.00 12/14/2011 .Jeff Recall Oral Exam 40.00 40.00 12/14/201 Jeff Adult Scale & Prophy 180.00 220.00 12/15/201' Jeff Ins Form submitted - Aetna Account Total 220.00 If payment has been sent, please disregard this statement - Thank You. We accept credit cards! You may complete top part of this statement, or call the office at Current 30 Days 60 Days 90 Days 120+ Days 220.00 0.00 0.00 0.00 0.00 Thomas J. MagnaniIM Alvin Grayson-. EFTA00312738