Please tell us some select information about your practice.
Name of Anesthesia Practice or Department:

Is the above Practice or Department a component or
affiliate of a larger anesthesia practice?

Ownership of the practice:
(Check all that apply.)

Location of primary business or departmental office:
Zip Code:

State(s) in which the practice provides patient care:

Does your group have its own Political Action Committee?
Does your group encourage providers to be members of the American Society of Anesthesiologists Political Action Committee?
Does the practice employ its own lobbyist?
Does your group require or encourage physicians to be members of American Society of Anesthesiologists?
Does the practice utilize in-house billing?
Does the practice have a centralized Quality Department?
Does the practice have centralized Risk Management?
Training Programs:
(Check all that apply.)

Approximate total number of facilities served:
(Check all that apply.)
Does the practice utilize an Electronic Medical Record?
Does the practice utilize an Anesthesia Information Management System?

Does the practice participate in anesthesia research?
Does the practice contribute data to the Anesthesia Quality Institute?

Approximate number of personnel employed:
Physician anesthesiologists:     
Nurse anesthetists:     
Anesthesiologist assistants:     
Pain Medicine Physician:     
Contact information for physician or administrative executive: Contact Full Name:

Contact Email:
Please provide feedback regarding your thoughts on American Society of Anesthesiologists:

©2014 AQI | 520 N. Northwest Highway | Park Ridge, IL 60068-2573 | Phone: 847-268-9192 | Fax: 847-825-5658 | Email: