Cornerstone Patient Survey

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* 1. Date of experience with our office

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* 2. Provider Seen

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* 3. What was your child seen for today?

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* 4. Please rate our level of care.

	Excellent	Good	Fair	Poor	N/A
Availability of appointment	Availability of appointment Excellent	Availability of appointment Good	Availability of appointment Fair	Availability of appointment Poor	Availability of appointment N/A
Was the scheduling staff knowledgeable and helpful?	Was the scheduling staff knowledgeable and helpful? Excellent	Was the scheduling staff knowledgeable and helpful? Good	Was the scheduling staff knowledgeable and helpful? Fair	Was the scheduling staff knowledgeable and helpful? Poor	Was the scheduling staff knowledgeable and helpful? N/A
How was your wait time to be seen?	How was your wait time to be seen? Excellent	How was your wait time to be seen? Good	How was your wait time to be seen? Fair	How was your wait time to be seen? Poor	How was your wait time to be seen? N/A
How would your rate the cleanliness of our facility?	How would your rate the cleanliness of our facility? Excellent	How would your rate the cleanliness of our facility? Good	How would your rate the cleanliness of our facility? Fair	How would your rate the cleanliness of our facility? Poor	How would your rate the cleanliness of our facility? N/A
Was the clinical staff knowledgeable and helpful during your visit?	Was the clinical staff knowledgeable and helpful during your visit? Excellent	Was the clinical staff knowledgeable and helpful during your visit? Good	Was the clinical staff knowledgeable and helpful during your visit? Fair	Was the clinical staff knowledgeable and helpful during your visit? Poor	Was the clinical staff knowledgeable and helpful during your visit? N/A
Overall care provided during this visit	Overall care provided during this visit Excellent	Overall care provided during this visit Good	Overall care provided during this visit Fair	Overall care provided during this visit Poor	Overall care provided during this visit N/A

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* 5. Please answer yes or no.

	Yes	No	N/A
Did the provider spend enough time with you and your child to answer all your concerns?	Did the provider spend enough time with you and your child to answer all your concerns? Yes	Did the provider spend enough time with you and your child to answer all your concerns? No	Did the provider spend enough time with you and your child to answer all your concerns? N/A
Would you recommend Cornerstone Pediatrics to your friends and/or family?	Would you recommend Cornerstone Pediatrics to your friends and/or family? Yes	Would you recommend Cornerstone Pediatrics to your friends and/or family? No	Would you recommend Cornerstone Pediatrics to your friends and/or family? N/A
Did you use the triage service prior to scheduling your visit?	Did you use the triage service prior to scheduling your visit? Yes	Did you use the triage service prior to scheduling your visit? No	Did you use the triage service prior to scheduling your visit? N/A
If yes, was your call returned promptly?	If yes, was your call returned promptly? Yes	If yes, was your call returned promptly? No	If yes, was your call returned promptly? N/A

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* 6. As we continue to be your child's medical home provider, please let us know what is going well or what we need to improve upon. Please include specific providers and staff names if possible.

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* 7. Is there someone you'd like to recognize for providing excellent care? If so, who and please tell us about your experience.

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* 8. Name

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* 9. Email