Date (skip if we've already discussed a date)

MM

DD

YYYY

Time (skip if we've already discussed a time)

Hour

Minute

Second

AM PM

Phone Number *

Real phone number only. Google Voice, burner phones will not be accepted in this field. You may *communicate* with me by Google Voice / VoIP phone number but your real number must be entered in this field. If you would like to communicate by a VoIP number, initiate contact through your real number and we will continue over your VoIP number.

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###

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Name *

First Name

Last Name

How would you like me to communicate with you when scheduling? Text or email? (if email, enter in the field below)

Text message

Email

How did you find me?

Rub Rankings

Tryst

Massage.Dating

Other

To prioritize the health of everyone, I respectfully request that you not schedule if you have any rashes, skin infections, or open wounds. I am unable to offer services in these situations for the safety of all. *

I understand that service will be refused if I arrive with any skin infections, rashes, or open wounds.

Confirm your identiy. *

I confirm that all of the above information regarding my identity is true.