<signature> AHN:

<signature> STATEMENT

APR-30-2009 10:10A FROM: DR THOMAS MAGNANI 2123979008 TO: 16467067223 P.1/1

AHN: Bella
STATEMENT

Thomas J. Magnani D.D.S.
Alvin Grayson D.D.S.
7 West 51st Street
7th Floor
New York NY 10019

From
Elizabeth

Telephone: 

If paying by credit card, enter the amount you are paying in the remittance box and fill out below.
 Mastercard
 Visa
 Amex

Card #: 
Exp Date: 

Signature: 
Sig Code: 

Jeff Epstein
St Thomas Virgin Islands 00802

Date: 4/30/2009
Account: 9118
Remittance:

IMPORTANT - PLEASE DETACH UPPER PORTION AND RETURN WITH YOUR REMITTANCE TO INSURE CREDIT TO PROPER ACCOUNT

<table><tr><th>Date</th><th>Patient</th><th>Description</th><th>Charges</th><th>Credits</th><th></th><th>Balance</th></tr><tr><td></td><td></td><td>Previous Balance</td><td></td><td></td><td></td><td>0.00</td></tr><tr><td>4/21/2009</td><td></td><td>Comprehensive Oral eval</td><td>50.00</td><td></td><td></td><td>50.00</td></tr><tr><td>4/21/2009</td><td></td><td>FMS with Bite wings</td><td>175.00</td><td></td><td></td><td>225.00</td></tr><tr><td>4/21/2009</td><td></td><td>Bite Wings 4 Films</td><td>65.00</td><td></td><td></td><td>290.00</td></tr><tr><td>4/21/2009</td><td></td><td>Adult Scale &amp; Prophy</td><td>160.00</td><td></td><td></td><td>450.00</td></tr><tr><td>4/21/2009</td><td></td><td>Fluorid</td><td>12.00</td><td></td><td></td><td>462.00</td></tr><tr><td>4/22/2009</td><td></td><td>AMERICAN EXPRESS</td><td></td><td>462.00</td><td></td><td>0.00</td></tr><tr><td>4/29/2009</td><td></td><td>1 Periapical X Ray</td><td>25.00</td><td></td><td></td><td>25.00</td></tr><tr><td>4/29/2009</td><td></td><td>Amalgam 4+ Surface Perm.</td><td>425.00</td><td></td><td></td><td>450.00</td></tr><tr><td>4/29/2009</td><td></td><td>Amalgam 4+ Surface Perm.</td><td>425.00</td><td></td><td></td><td>875.00</td></tr><tr><td colspan="7">Account Total 875.00

Wo accept credit cards You may complete and return the top part of
this statement, or call the office at 212888.1090.</td></tr><tr><td>Current</td><td></td><td>30 Dayt 60 Dayc</td><td>00 Dayc</td><td></td><td>120</td><td>Days</td></tr><tr><td>875.00</td><td></td><td>0.00 0.00</td><td>0.00</td><td></td><td>0.00</td><td></td></tr></table>