Center for Anti-Aging Pandemic Survey
RequiredRequired Question(s)
Required 1.
What is your name?
 

50 characters left.
Required 2.
Have you traveled to any of the following states within the last 14 days? 
-Alabama 
-Arizona
-Florida
-Georgia
-Idaho
-Nevada
-South Carolina
-Texas
-Mississippi
 

50 characters left.
Required 3.
Have you or anyone in your immediate family been sick with a fever >100.4 or any respiratory symptoms including cough, shortness of breath or loss of taste/smell?
 

50 characters left.
Required 4.
Have you had any known exposure to anyone with COVID-19?
 

50 characters left.
Required 5.
If you are a healthcare worker, have you had any unprotected exposures to patients with COVID-19?
 

50 characters left.
Please remember to wear a mask while out in public as much as possible, wash your hands, use hand sanitizer and stay home if you feel ill or have been exposed to someone who is sick. Thank you for helping to keep our community safe! We look forward to seeing you!
After you complete this survey you can text us at 859-359-8444 with any questions or to let us know you have arrived.