Thank you for choosing Gailey Eye Clinic for your vision care.  For your convenience we’ve made a few of our forms available to you online.  If you are a new patient who would like to be ahead of the game when you arrive for your first appointment, please print and complete the New Patient Form and  bring it with you to your appointment.  If you are a patient requesting your medical records from Gailey Eye Clinic, please fill out the Medical Records Release and fax, mail, or bring it in to the office to receive a copy of your records.

New and Existing Patients:

Note that dilating drops may be used at your exam.  These drops allow the doctor to see inside your eye, which is the only way to thoroughly evaluate your eye health. Dilating drops affect people differently, and on some occasions may temporarily blur vision and increase sensitivity to bright lights.  Also, some people have difficulty driving immediately after the exam.  We cannot predict the affect on your vision.  Therefore, you may want to make special transportation plans or bring a driver with you on the day of your exam.  On sunny days, you will be more comfortable exiting the office with sunglasses.  You are encouraged to bring sunglasses with you, however we can provide a  disposable pair for you if you do not have any with you at the time of your exam.

We hope you find this information helpful.  Feel free to contact us with any questions.


New Patient Form

Please click here to fill out this form and bring it with you to your initial appointment (for new patients only).


Medical Records Release

Please click here to fill out this form if you are requesting a copy of your medical records.


Notice of Privacy Practices

Please click here to view this notice on your medical information


Surgical Information Forms

If you are having surgery, such as cataract, corneal, retinal, oculoplastic or any other surgery that requires anesthesia, please click here for pre-surgical information*


Laser Information Forms

If you are having one of the following laser procedures (Peripheral Iridotomy, SLT, or YAG laser), please click here for laser information*


NonDiscrimination /
Antidiscrimination Forms

*If you are not scheduled to undergo surgery at the Bloomington Eye Institute or Gailey Eye Surgery-Decatur, please contact your surgical scheduler for more information.

Patient Forms
PHONE 800.325.7706

Bloomington/Normal: (309) 829-5311
Bloomington/Retina: (309) 829-5311
Champaign: (217) 398-1700
Danville: (217) 446-3937
Decatur: (217) 875-0300
Forsyth: (217) 872-7404
Galesburg: (309) 343-6000

Gibson City: (217) 784-8442
Ottawa: (815) 434-4200
Pekin: (309) 347-5115
Peoria: (309) 692-8460
Peru / Lasalle: (815) 224-1100
Springfield: (217) 529-3937
Watseka: (815) 432-2020