Form

Items marked with a red asterisk are required.

This form is for serious inquiries only. If you do not intend to schedule and show up for a session, do not use this form.

If you provide false, incomplete, or misleading information, you will be forever banned from Chicago Dungeon.

This form is encrypted and the information you provide is forwarded securely to a private e-mail account, so your information is perfectly safe. After your session, your form will be permanently deleted, so your information has no chance of falling into the wrong hands.

Thank you for your cooperation.

Full Name (first and last names as they appear on your government-issued ID, IF YOU FAIL TO PROVIDE YOUR FULL NAME, YOUR FORM WILL BE DELETED)*

Cell Phone Number*

E-mail Address*

City (as it appears on your government-issued ID)*

State (as it appears on your government-issued ID)

Country*

Occupation*

Gender*

Date Of Birth*

Month Day Year

Ethnicity*

Height*

Weight (lbs)*

Hair*

Eyes*

Distinct Features

Disabilities/Physical Anomalies/Allergies/Medical Conditions (which may affect your session)

How did you find my Web site (e.g. Max Fisch, Dickie Virgin, Google, Yahoo!, etc.)?*

If you saw a professional dominatrix within the last year, enter her Web site here.

What kind of session do you want?*

In-call (you come to me) Out-call (I come to you)

If you want an out-call, where will I be coming?

Which theme room/persona do you wish to visit?*

What arrival date and time is your first choice for our session? What date do you wish to see me? If you do not know yet, do not fill out this form. Wait until you decide on a date. I DO NOT DO SAME DAY APPOINTMENTS! I NEED AT LEAST 24 HOURS NOTICE! ALSO, I ONLY BOOK TWO WEEKS OUT, SO DON'T ASK FOR A SESSION MORE THAN TWO WEEKS AWAY! WAIT UNTIL TWO WEEKS BEFORE YOU WISH TO SEE ME, THEN FILL OUT THIS FORM! TO SUM IT UP, FILL OUT THIS FORM ONE DAY TO TWO WEEKS PRIOR TO SEEING ME!*

/ Month / Day Year

at

: Hour Minutes

How long of a session do you desire?*

Comments: This is the place to mention special requests, what you are into, etc.. If you mention illegal activities like sex acts (prostitution), full-body worship, penetration (fisting, dildos, strap-on, etc.), massage, or forced bi, your form will be deleted and you will be permanently banned from Chicago Dungeon.

Do you understand and agree that this form is intended to schedule a session for professional BDSM and fetish exploration, and that penetration, prostitution services, massage, sex acts, etc. are not offered? (Please, note that if you act like a lunatic and request an illegal act during your session, you will be removed from the premises and forfeit your session fee. Please, don't embarrass yourself by exhibiting your desperation and willingness to be a turd.)*

Yes No

Type what you see into the space below to prove you are human. If you can't read the image, use the refresh button.*