EFTA02700327

FEB-13-2003 10 35 FROM:OR.WMANI TO: P.1'3 -ttd: Il& Thomas .1. Magnin, D.D.B. Alvin Grayson Milt 7 West 61st Stint 7th Floor New York NY 10010 Mr. Jeff Epstein 301 East 66th Street Apt 310F New York NY 10065 Cate Patient Deacripdon 11/6/2013 11/8/2013 11/6/2013 Svetleana Svetleana Svetleana Recall Oral Exam Adult Scale & Prophy Bite Wings 4 Films urfaoe Perm. Current 30 Days 80 Dee 11/6/2013 to 2112/2014 HISTORICAL STATEMENT Telephone: DS AtOount I 2/12/2014 9293 Charges Credits Balance 40.00 40.00 180.00 220.00 66.00 285.00 376.00 880.00 Account Total 660.00 Patent Charges 610.00 Patient Payments 0.00 Patient Credits 0.00 Patient Debits 0.00 90 Cloys 120+ Days Thomas. Moonain AMn orintyoon 0.0.8 7 Woof Mot Si et 791 Floor Now Yolk NY 19019 EFTA_R1_02065815 EFTA02700327