Name of Clinic

Month, Year

---

Name of Technician (Clinic Owner)

Total Earnings: $

---

​Baseline Assessments
Total: ​#

Date     Client's Name     Phone #

Date     Client's Name     Phone #

​Date     Client's Name     Phone #

---

​Follow-Up Assessments
Total: #

​Date     Client's Name     Phone #

Date     Client's Name     Phone #

​Date     Client's Name     Phone #

---

Therapeutic Fitness Trainings
Total: ​#

​​Date     Client's Name     Phone #

Date     Client's Name     Phone #

​Date     Client's Name     Phone #

---

Clinic Reports

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Month, Year = June, 2025 (example)

Total Earnings = The total amount ($) that the Assistant Technician earned during this month by providing Services at this Clinic.

Client's Name = LastName, FirstName

​Clients are listed in chronological order by Date of Service

Clinic Reports