Survey Disclaimer

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Survey Disclaimer

You are invited to participate in a web-based online survey on This is a health questionnaire being conducted by GeeVida Health for the purpose of preliminary sexual health assessment.  It should take approximately 10 minutes to complete.


Your participation in this survey is voluntary. You may refuse to take part in the research or exit the survey at any time without penalty. If you are asked in the survey to reveal your identity and don not with to do so, please not respond the survey. You are free to decline to answer any particular question you do not wish to answer for any reason.


It is vital for many medical practices to prepare for patients, especially new ones. Being able to research and read about the patient’s history and expectations before they enter the office is a huge advantage. It can completely change that initial meeting outcome.

The online patient intake form helps to improve accuracy by giving patients a way to complete their forms from the comfort of their homes. This lets them take their time when filling out the form, checking over what they are filling out as they fill it out.

Improved work from staff is another benefit of the online patient intake form. The online intake form reduces the heavy workflow that the front office staff often experiences.


There are no foreseeable risks involved in participating in this study other than those encountered in day-to-day life.


There is the risk that you may find some of the questions to be sensitive.


The possible risks or discomforts of the study are minimal. You may feel a little [uncomfortable/embarrassed/sad] answering [personal/sensitive] survey questions.


We will do our best to keep your information confidential. All data is encrypted and stored in a password protected electronic format. Your survey answers and results will be presented and sent to you and Geevida Health providers and team where data will be stored in encrypted format.  At the end of the survey you may be asked if you are interested in participating in an additional [interview/information/appointment]

The sexual health assessment survey terms and conditions of Use, Legal Disclaimer, and privacy statement contain important information about your rights and obligation as user of the website. All visitors to the website are being provided access to the sexual health assessment page free of charge, subject to the following Terms and Conditions of Use. If you have questions, please contact us.


If you have questions at any time about the survey, you may contact GeeVida Health team via phone at 866.433.8432 or via email at [email protected].

Electronic Consent. Please select your choice below.

Clicking on the check box button indicated that:

-You have read the above information

-You voluntarily agree to participate

-You are at lease 18 years of age

If you do not wish to participate in the research study, please decline participation.