Health Questionnaire 
Please fill out the following health declaration form in order to maximise your appointment time.
Please tick any of the following conditions that you may have

All information given is treated with the strictest level of confidence and will not be divulged to a third party, except a health professional if we transfer your care to them, without prior consent.

Informed Consent

Your Signature

THE CLINIC

MaxPhysio

Primary Care Centre,

Clarke Street,

Clonakilty,

Co Cork,

P85 XE95

Email: info@maxphysio.ie

Tel: 021 4193003

Opening Hours:

Mon - Thurs: 9am - 8pm

Friday: 9am - 6pm 

​​Saturday: 9am - 1pm ​

Sunday: Closed

CONTACT

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