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* 1. Date of Service

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* 2. Name of Facility

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* 3. Anesthesia Provider's Name

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* 4. During the visit with the anesthesia team, I was able to ask the questions I wanted.

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* 5. To what degree were you satisfied with the amount of information given by providers?

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* 6. The CRNA explained to me how I would feel after anesthesia.

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* 7. To what degree did you find your anesthesia providers to be professional?

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* 8. I would want to have the same anesthetic again.

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* 9. How satisfied were you with the care provided by anesthesia department?

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* 10. I would recommend the anesthesia team to others in my family.

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