Exceptional DentistryBeverly A. Rose D.M.D., P.A.

2755 N. Wickham Rd.Suite 101

Melbourne, FL 32935(32t\259-4666

March 02,2015

Andrei M. Szabo1757 Sun-Gazer DriveRockledge, FL 32955

lD: 10066

Account Aging

Current:

30 Days:

60 DaYs:

90 DaYs:

Contract:

Balance Due:

Estimated lnsurance:

Balance Due Now;

$112.00

$0 00

$0.00

$0.00

$0 00

Datg

03t0212Q15

Patient

Andrei

Andrei

Andrei

Andrei

Andrei

Andrei

Provider

Beverly Rose, DMD

Beverly Rose, DMD

Beverly Rose, DMD

Beverly Rose, DMD

Beverly Rose, DMD

Transaction

02392 - RESIN.2 SURFACES, POST.PERMANENT(Est lnsurance $28.00)

02392 - RESIN-2 SURFACES, POST-PERMANENT(Est lnsurance $28.00)

02392 . RESIN.2 SURFACES, POST-PERMANENT(Est lnsurance $28.00)

01351 . SEALANT.PER TOOTH

02331 - RESIN-2 SURFACES, ANTERIOR(Est lnsurance $28.00)

Acct Pmt - Master Card Card # MasterCardXXXXXXXXXXXX503S for ($893. 50)

$1 12 00

112.00

$0.00

6

Surface ECgDO $235.00

DO $235 00

oL $235.00

$54.00

DL $235 00

SubTotal: $994.00Tax: $0.00

Today's Charges: $994'00Today's Payment: $893 50

PreviousBalance: $11.50

Balance Due: $112 00Estimated lnsurance: $1 12 00

Adjustments BalanceToday Due Now

uh4

ContractBalance

Estimatedlnsurance

PreviousBalance

ChargesToday

PaymentsToday

$0 00 $1 12.00 $11.50 $994.00 $893.50 $0.00 $0.00

-/,tr^,,,i, :i:,i:t'"t:"

SIGNED

I agree to pay the above payment amount according to my card issuer agreement

Future Family Appointments:Patient: Next Appointment; Patient: Next Appointment: Patient: Next Appointment

10066 Andrei Szabo 311612015@ 3:00pm10066 Andrei Szabo 811012015@ 3:00pm

6057 Lenuta Roberts 41612015@ 1:30pm 5930 Kyle Roberts 512012015@ 3:00pm

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