Medical Scene Request

MEDICAL SCENE

Fill out the below details for the scene you have requested.
General Information
Name of client. (need first name so it matches photo submission) *

First Name Scene name
Email
example@example.com
Phone Number of client setting the scene up. *
Date of scene *

Month Day Year
Date
Venue and location of scene to be carried out. I.e A club name and a particular room. *
What role is the client? *
What is the born sex of the target? *

Male Female
Date of birth of the target *

Month Day Year
Date
Target Approx weight *
Target height *
Do you agree to be taken by force if you try to escape?. *

YES NO
What will the client be wearing on the day ? (place any items of clothing IN CAPITALS that you will allow to be torn or cut off). *
List items of clothing that can be removed without damage or put NONE. *
Description of target. I.e Hair colour, skin colour, tattos etc. *
Medical history. Give details of any medication, epilepsy, diabeties, medication, surgery or body modifications such as percings. *
Has the client any allergies? if none put NONE. *
If client needs medication such as inhaler, client responsbillity to ensure its available.

NONE YES

On this scale how would you rate your pain tolerance? *

	1	2	3	4	5	6	7	8	9	10

1 is LOW, 10 is HIGH

How would you rate likley hood to resist being taken to the scene room? *

	1	2	3	4	5	6	7	8	9	10

1 is NONE, 10 is VERY MUCH

Select primary scene request (Up to two selections) *

Cunt stitching FULL Cunt stitching Half Cunt staples Dental check up Dental torture Cavity exploration (Anal) Cavity exploration (Cunt) Sounding Lip suturing
Secondary (Plan B) Up to two selections.

Cunt staples Lip suturing Cavity exploration (Anal) Cavity exploration (Cunt) Dental check up Sounding
What you want to be considered to be in the scene

USE OF HANDS & FEET

USE OF ITEMS / MISC

Will you like to have a partner involved / in the room with you during the scene. Type NO or the name of the person(s)
I (Client) CONSENT TO PHOTOS BEING TAKEN

YES NO
I (Client) CONSENT TO VIDEO BEING TAKEN

YES NO
I (Client) CONSENT TO SOUND BEING TAKEN

YES NO
I (Client) CONSENT TO BRUISING AND MARKS ON MY SKIN relevantto the scene I have chosen.

YES NO
I (Client) consent to this scene & the above information.I have selected at my own free will. Type your full name as on your ID to sign this form.

First Name Last Name
Extra Information
ADD A RECENT FACE PICTURE OF TARGET HOLDING A SIGN
WITH THE FOLLOWING WRITTEN ON IT:

DATE

NAME

"I CONSENT TO BE THE CLIENT"
Select Picture

Cancel of
ADD A PHOTO FOR PROOF OF ID FOR TARGET TO BE 18+

YOU CAN BLANK OUT ANY ADDRESS ON SHOW
Browse Files

Cancel of
Anything else you would like to add?
Enter the message as it's shown *
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

MEDICAL SCENE