STATEMENT

STATEMENT Date Thomas J. Magnani D.D.S. Alvin Grayson D.D.S. 7 West 51st Street 7th Floor New York NY 10019 Mr. Jeff Epstein 301 East 66th Street Apt 10F New York NY 10065 Telephone: (212) 688-1090 OolOn0 by Croat owe Genet Ono amount you are porno in the recarlIonce box and id Out below lolantorcood _ Vaa Amex CVO Sognatunio iv Dam S9 Cede Date Account 1/5/2011 9648 Remittance IMPORTANT • PLEASE CETACH UPPER PORTION AND RETURN WITH YOUR REMITTANCE TO MORE CREDIT TO PROPER ACCOUNT 11/24/2010 11/22/2010 11/22/2010 11/22/2010 12/13/2010 12/13/2010 12/14/2010 12/14/2010 12/17/2010 Patient Description Charges Credits Balance Renata Renata Renata Renata Renata Renata Renata Renata C12-/20/2019‘` Renata Previous Balance FMS with Bite wings Amalgam 1 Surface Perm. Amalgam 3 Surface Perm. Comp. W. Etch 1 Surface Comp. W. Etch 1 Surface Comprehensive Oral eval Adult Scale & Prophy MASTER CARD Porcelain W. Gold Crown 175.00 325.00 375.00 275.00 275.00 50.00 160.00 (1,850.00 1,425.00 0.00 175.00 500.00 875.00 1,150.00 1,425.00 1,475.00 1,635.00 210.00 2,060.00 Account Total 2,060.00 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 2,060.00 0.00 60 Days 90 Days 0.00 0.00 120+ Days 0.00 Thomas J. Magnori D.D S. Alvin Grayson D D.S 7 Wost 51st Stroot 7th Floor Now York NY 10019 EFTA01156639