Consent to Treat Minor - Gailey Eye Clinic

Consent to Treat Minor Without Parent/Legal Guardian Present

If you would prefer to download a PDF version of this form and return it to the office, please click here.

Patient's Full Name*
First Last
Date of Birth*
Month
Day
Year
To allow for treatment of patients who are considered minors, it is necessary for a parent or legal guardian to give consent for treatment. In the event that a minor child presents for a non-urgent appointment without a parent or legal guardian or a signed consent, treatment may be denied.
To Consent To:
- Emergency or urgent care when I cannot be reached.
- Routine eye exam, which will include vision check, refraction, glaucoma test, dilation of pupils, examination by one of our providers , and any other treatment previously discussed and agreed upon by the parents/legal l guardian.
I can be reached at the following number if there are any questions:*
Parent/Guardian Name*
First Last
Today's Date*
MM slash DD slash YYYY
Agreements*
- By checking this box, I agree that all information is correct and an accurate representation of myself.
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Phone
This field is for validation purposes and should be left unchanged.

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

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