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 ClinicSaturday, December 7th, 2019 at 2:00pm

Check back with us on Monday when the 12 Days of Giving continues.

Days 5-9 are full of goodies for music lovers, shoppers, and techies!

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Gailey Eye ClinicFriday, December 6th, 2019 at 2:38pm

Day 4: Fossil Leather Backpack!

Register to be entered to win today's gift. The winner will be announced on Monday. This offer is valid for today only, December 6th!

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

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Gailey Eye ClinicThursday, December 5th, 2019 at 3:10pm

Day 3: Free, non-prescription sunglasses (up to $250)

Register to be entered to win today's gift. The winner will be announced tomorrow. This offer is valid for today only, December 5th!

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*
Date Format: 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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