Appointment Request Form
Name
Email
Age
Phone #
City/ State for Appt
Date
Time
# of Hours
Have you ever seen a Professional Dominatrix Before?
Yes
No
How did you find Me?
Name & URL, Reference #1
Email
Name & URL, Reference # 2
Email
Name & URL, Reference # 3
Email
How would you classify yourself?
Kinkster
Fetishist
Submissive
Masochist
(you may select more than one)
Interests
ABDL
Blindfold
Boot Worship
Boot Domination
Breath Play
Caning
CBT
Chastity
Enema Play
Face Slapping
Financial Domination
Flogging
Foot Worship
Foot Domination
Gags
Glove Fetish
Hand Over Mouth
Heavy Rubber
Humiliation
Latex
Leather Fetish
Leather Restraints
Medical Play
Military Fetish
Mouthsoaping
Needle Play
Nipple Play
Nipple Torture
Orgasm Control
Orgasm Denial
Paddling
Pantyhose Bondage
Pantyhose Fetish
Rope Bondage
Scarf Bondage
Sensory Deprivation
Single Tail Whipping
Small Penis Humiliation
Smoking Fetish
Smoke Domination
Smothering
Spanking
Spitting
Straitjacket
Slut Training
Tease and Denial
Tickling
Trampling
Urethral Sounds
Roleplay Scenarios
Boss
Ex-Lover
Interrogation
Mean Mommy
Nurse
Secretary
Strict Mistress
Teacher
Limits
Things you definitely don't want to do, medical issues/limitations
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