Exceptional Dentistry

Beverly A. Rose D.M.D., P.A.

2755 N. Wickham Rd.
Suite 101
Melbourne, FL 32935
(32t\259-4666

March 02,2015
Account Aging

Andrei M. Szabo
1757 Sun-Gazer Drive
Rockledge, FL 32955
lD: 10066

Provider

Patient

Datg
03t0212Q15

Beverly Rose, DMD

Andrei

Current:

$112.00

30 Days:

$0 00

60 DaYs:

$0.00

90 DaYs:

$0.00

Contract:

$0 00

Balance Due:

$1 12 00

Estimated lnsurance:

112.00

Balance Due Now;

$0.00

uh

Transaction
02392 - RESIN.2 SURFACES, POST.PERMANENT

Surface
DO

$235.00

DO

$235 00

oL

$235.00

ECg

(Est lnsurance $28.00)

Andrei

Beverly Rose, DMD

02392 - RESIN-2 SURFACES, POST-PERMANENT

(Est lnsurance $28.00)

Andrei

Beverly Rose, DMD

02392 . RESIN.2 SURFACES, POST-PERMANENT

(Est lnsurance $28.00)

Andrei

Beverly Rose, DMD

01351 . SEALANT.PER TOOTH

Andrei

Beverly Rose, DMD

02331 - RESIN-2 SURFACES, ANTERIOR

(Est lnsurance $28.00)

$54.00

DL

$235 00

Acct Pmt - Master Card Card # MasterCard

Andrei

XXXXXXXXXXXX503S for ($893. 50)

SubTotal:
Tax:

$994.00

Today's

Charges:

$994'00

Today's

Payment:

$893 50

$0.00

PreviousBalance:
Balance
Estimated
Contract
Balance

Estimated
lnsurance

$0 00

$1

12.00

Previous
Balance

Charges
Today

Payments
Today

$11.50

$994.00

$893.50

Due:

lnsurance:

Adjustments
Today
$0.00
-/,tr^,,,i,

$11.50

$112 00
$1 12

00

Balance
Due Now
$0.00

:i:,i:t'"t:"

SIGNED
I agree to pay the above payment amount according to my card issuer agreement
Future Family Appointments:
Patient:

10066
10066

Szabo
Andrei Szabo
Andrei

Next Appointment;

Patient:

311612015@ 3:00pm

6057

Lenuta

Roberts

Next Appointment:

Patient:

41612015@ 1:30pm

5930

Next Appointment
Kyle

Roberts

512012015@ 3:00pm

811012015@ 3:00pm

Page
Current Dental Terminoloov CCDT)

O American Dental Association (ADA). All rights reserved.

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