Ruby la Rouge BDSM Client Form
Please read the Terms of Agreement for New Clients and complete the following form to schedule an appointment.
This form will take between 15-45 minutes to complete.
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Email *
Scene Name or Nickname *
Phone number
Gender *
Role *
Pain tolerance *
Sexual preference *
How easy is it for you to achieve an orgasm? *
How easy is it for you to achieve an erection (or to become aroused for those who identify as female)? *
Allergies: *
Physical Impairments: (eg. bad back, epilepsy, etc) *
Phobias/Abuse Issues: *
Preferred Method of Contact for Consultation: *
Required
Type of Scene Desired: *
Required
How experienced are you with BDSM? *
How did you hear about me? *
Which services interest you? *
Required
Permission to be photographed for advertising purposes? *
Have you ever had a bad experience with a Dom? *
Required
If so, what went wrong/How can I do things differently?
Specific Clothing/Toy/Activity/Equipment Requests: (optional)
Comments and/or Additional Information: (optional)
Anal: (if of interest, select all that apply)
Bondage: (if of interest, select all that apply)
Genitorture, Cock & Ball Torture or Vaginal Torture (if interested, select all that apply)
Discreet Public Play: (if of interest, select all that apply)
Gags: (if of interest, select all that apply)
Material Fetish: (if of interest, select all that apply)
Nipple Play: (if of interest, select all that apply)
Orgasm Control: (if of interest, select all that apply)
Pornography/Scene Pictures or Filming (BDSM Related): (if of interest, select all that apply)
Power Exchange: (if of interest, select all that apply)
Role Playing: (if of interest, select all that apply)
Sensation Play: (if of interest, select all that apply)
Sensory Deprivation: (if of interest, select all that apply)
Fun Domme: (if of interest, select all that apply)
Clear selection
S&M: (if of interest, select all that apply)
Verbal: (if of interest, select all that apply)
If Verbal "Dirty names", please specify:
Watersports - Urine Only: (if of interest, select all that apply)
Worship only: (if of interest, select all that apply)
Miscellaneous:
Clear selection
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