Appointment Request - Gailey Eye Clinic

Need to schedule your next appointment? We offer 3 easy ways to do it! Choose whichever option works best for you!

Option 1) Complete the form below and click Submit
Option 2) Contact your local Gailey office by phone HERE
Option 3) Text us at 309.829.5311

Our staff are waiting to help you! Once we receive your appointment request, we’ll get back with you shortly!

Request Appointment Online

"*" indicates required fields

Name*

First Last

Email*

Phone*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Patient Status*

Patient Information

Patient's Date of Birth*

Does the patient wear contacts?*

Yes

Medical Insurance Carrier*

Vision Insurance Carrier

NOTE: Gailey Eye Clinic is not in network with ACA plans including Molina, Meridian, and Aetna Better Health.

Appointment Date & Time

Preferred Date*

Alternate Date

Location*

Time*

Anytime

Morning

Afternoon

Additional Information

Comments or Questions?

This field is for validation purposes and should be left unchanged.

Please be advised that emails sent through this form may not be fully secure and may not be protected under HIPAA. We recommend avoiding sensitive or confidential information in your messages. Please contact us directly via phone or other secure methods if you need to share sensitive information.