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

Jeff Epstein
9 East 71st Street
New York NY 10021

Telephone: ██████████

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

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Card # <empty>
Exp Date <empty>
Signature <empty>
Sig Code <empty>

Date: 3/30/2016
Account: 3114
Remittance: <empty>

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>3/2/2016
3/7/2016</td><td>Jeff</td><td>Previous Balance
Temporary Cement</td><td>375.00</td><td></td><td></td><td>0.00
375.00</td></tr><tr><td>3/30/2016</td><td>Jeff</td><td>1 Surface Comp. Posterior</td><td>425.00</td><td>r '</td><td>a C</td><td>800.00

6it</td></tr></table>

Account Total 800.00

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

<table><tr><th>Current</th><th>30 Days</th><th>60 Days</th><th>90 Days</th><th>120+ Days</th></tr><tr><td>800.00</td><td>0.00</td><td>0.00</td><td>0.00</td><td>0.00</td></tr></table>

From: ███████████████████████████████████
Subject: Jeffrey and doctors-Wed. March 30th, 2016
Date: March 29, 2016 at 11:39 AM
To: Bella Klein bklein575@gmail.com



FYI...Jeffrey is going to see Dr. Magnani tomorrow at 9am and Dr. Kline at 10am (Magnani for a cavity and Kline is a dermatologist)