STATEMENT OF ACCOUNT

CHART NO. PAGE NO.

First C hoice Oental Group 99561 1
440 Science Orive. Suite 100
81l.LING DATE
Madison, WI 53711
04111/2018
(608)308-2950 CREOfT CARO# EXP

NAME
GUARANTOR MAME AHO MAILING AOOAESS

SIGNATUAE

TYPE OF CARO AMOUNT ENCL OSED

s
TO INSURE PROPER CREDIT, PLEASE DETACH AHO RETURN THIS P0Rl10N OF THE STATEMENT WITH YOUR PAYMENT

"UM€ FtfTAIH THI$ PORTION Of' rHetrATFue,iTFOlt VOVR RECORO'$

DATE DESCRIPTION PATIENTS NAME CHARGES CREtmll

03111/2018 Balance FOfWard 0 .00

0410912018 Advl1 New Patient V1$it 0 .00

04/0912018 Periodonlal Tx Recommendation 0 .00

• 0410912018 Comprehensive oral evaluation 74.00

• 04/0912018 Full Mouth X-ray 149.00
• 04/0912018 TopicaJ nuoride varnish 29.00
04111/2018 Payment • Oetta Dental of WI C k# 1234 -223.00

"Indicate& tha1 i suranc8 has been billed 1or the procedure.

CURRENT BALANCE OVER 30DAY$ 0~600AYS OVER90DAY$ TOTAL BALANCE INSURANCE EST.

o.oo
29.00 0.00 0.00 29.00
i 0.00

OUE: May 4, 2018. Make easy OnlrMt paymeots at our webUe www.flr&tchoicederrtal.com
Please call yoor dental offioe wih any questions r~rdlng this statement
PLEASE PAY
THIS AMOUNT .. I 29.00
I