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 complete the New Patient Form.  If you are a patient requesting your medical records from Gailey Eye Clinic, please fill out the Medical Records Release 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.

CATARACT-FLASH_beach1-150x150New Patient Form

Please click here to fill out this form in advance of your initial appointment (for new patients only).

cosmeticMedical Records Release

If you are requesting a copy of your medical records, please click here to download, complete the form and then return to our office.

GLAUCOMA_male_23-150x150Notice of Privacy Practices

Please click here to fill out this form.

cataractsSurgical 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*

consent-to-treatConsent to Treat Minor Form

If you need to treat a minor without a parent/legal guardian present, please click here to fill out the form.

Antidiscrimination Forms


Patient Forms
PHONE 800.325.7706

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

Gibson City: (800) 325-7706
Ottawa: (815) 434-4200
Peoria: (309) 692-8460
Peru / Lasalle: (815) 224-1100
Springfield: (217) 529-3937