| Your Name |
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| Your Email Address |
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| Your Location |
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| Your Age |
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| Height and Weight |
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| Medical Problems(including allergies) |
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| How do you rate you experience level? |
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| Have you ever been to a Pro Domme before? If yes who? |
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| Describe your fantasies: |
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| Describe your best BDSM experience: |
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| Describe your worst BDSM experience: |
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| How would you describe you body language and reactions during a scene? |
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| Can you leave a session with marks? |
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| Tell Me why you wish to serve me: |
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| Are you associated with any law enforcement agency? |
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| How did you find out about Me: |
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| On a scale of 1 to 10 (1 being not exciting 10 being very exciting), does pain excite you? |
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| Single Tails |
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| Floggers |
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| Paddles |
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| Canes |
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| Crops |
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| Straps |
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| Belt |
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| Spankings |
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| Scratching |
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| Tickling |
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| Cock and ball torture (CBT) |
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| Nipple torture(NT) |
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| Wax play |
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| Fire play (including fire cupping, fire batons, fire flogging): |
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| Sensation play (Unusual textures such as feathers, silk, or leather) |
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| Sensory deprivation (blindfolds or hoods and earmuffs) |
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| Breath control play |
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| Erotic electro stimulation (TENS, PES Power Box, EMS units, Violet wand) |
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Bondage(rope, straps, harnesses, spreader bars, x-frames, chains: including police handcuffs, thumbcuffs and belly chains, hogtie, spread eagle)
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| Mummification (saran wrap, clingfilm, cloth, bandages, rubber strips, duct tape, plaster bandages, bodybags, or straitjackets) |
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| Boot/foot worship |
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| Animal roleplay (petplay, ponyplay, ponyism, kittenplay, or pup-play) |
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| Urethral sounding |
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| Scrotal Infusion (must be prepared to allow 24 to 72 hours for saline to be absorb back into body) |
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| Objectification: footstool, ashtray |
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| Trampling |
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| Body Punching |
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| What kind of role play are you into? |
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| Anything else you wish to add? |
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| When do you wish to have your session? |
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| A deposit is required to hold you session, which method of payment do you prefer? |
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| Image Verification |  | |
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