Gailey Eye Clinic

We are committed to providing our patients with the most advanced, progressive, and highest quality eye care available. •Central Illinois•800.325.7706 http://www.GaileyEyeClinic.com/

Gailey Eye Clinic

Gailey Eye Clinic is a renowned, multi-physician, multi-location vision care practice in Central Illinois. Our skilled physicians and staff strive to provide you with the highest quality of care in a professional, friendly environment. We feel privileged that you have trusted us with your care.

Gailey Eye ClinicWednesday, December 19th, 2018 at 4:28pm

We want to give a HUGE thank you to everyone who participated these last few weeks and made the 12 Days of Giving such a great success!! Happy holidays!

Our Day 12 of Giving winner is Brian S. from the Bloomington/Normal area. Brian won the final gift of Bladefree Lasik. Congrats!!😄🎉

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Gailey Eye ClinicTuesday, December 18th, 2018 at 4:58pm

Our Day 11 of Giving winner is Dayne J. from the Peru/LaSalle area. Dayne won a Beats Pill + Bluetooth Speaker. Congrats!!😄🎉

Thank you to everyone who participated!

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Gailey Eye ClinicTuesday, December 18th, 2018 at 6:00am

Day 12: See the difference for yourself!!

Register to be entered to win today's gift. Winner will be announced tomorrow. This offer is valid for today only, December 18th!

**Must be 18-years or older to qualify.

Click here to register: http://bit.ly/2AEiajn

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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*
MM
DD
YYYY
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*
Agreements*
- By checking this box, I agree that all information is correct and an accurate representation of myself.
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