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 us by phone at 800.325.7706
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's Date of Birth*

Does the patient wear contacts?*

Yes

Insurance Carrier*

Policy Number*

Preferred Date*

Alternate Date

Location*

Time*

Anytime

Morning

Afternoon

Comments or Questions?

Phone

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