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About You

Where did you see my advertisement? *

Have you been tested for covid? *

Have you been vaccinated from covid 19?

First Name: *

Last Name: *

Age: *

Mobile Number: *

In what city/country were you born, and raised? *

City (currently living in): *

Ethnicity: *

Occupation: *

Do you have a LinkedIn Profile? Yes or No? If Yes, send the link to your profile. *

Personal email: *

Work email (optional):

Have you traveled within the last month? If so, where? *

Zodiac sign? *

Relationship Status: *

Do you have Twitter, or Instagram or Facebook? Yes or No? If Yes, send the links to your profiles. *

Favorite Movie? *

Favorite color? *

Rough, Sensual, or a little of both? *

Do you have pets? *

Favorite genre of music? *

Low Key, or Center of Attention? *

Are you a morning person? *

Photo (optional):

Photo ID (optional):

Appointment Request

Will this be our first meet? If so, their is a 90 minute minimum for new friends. *

What date and time did you want to meet?

Incall or Outcall? (You come to me or I travel to you): *

If yes to Outcall, address? *

How long do you want to hang out for? *

Did you see the rates for our time together? *

Would you like me to save your number in my contacts? If no, your info is deleted after our first meet. *

Sexual Health

Are you currently sexually active in your relationship/marriage? *

Have you ever had an STD? *

If yes to previous question what year, and treatment.

Have you ever a blood test specifically for Herpes simplex HSV-2? *

Have you ever tested positive for Herpes simplex HSV-2? If so, what year, and what treatment are you currently on? *

Have you ever tested for HPV? *

Have you ever tested positive for HPV? If yes, what year, and treatment?

References

Name of the last provider (escort, sex worker) you have visited within the last 6 months? Please include website or number. *

Are you a Usasexguide member? *

Amp Review board username? *

TNA board username? *

Are you a member of any provider board’s? *

Thank You for filling out the screening form. Do you want me to contact you for an appointment? *

My screening form is fun, quick, and easy.

I would like to know a little more about you before we meet. It makes for a better encounter.

The screening process is a crucial as it establishes a threshold for any future encounters. Only serious and respectful inquires will be considered. If you choose to forego I understand and thank you for your interest.

For same day incall/outcall appointments.

Call 914.216.1222

At my discretion, I may require a $50 deposit by Amazon e-giftcard, or Venmo.

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About You

Appointment Request

Sexual Health

References