Nurse Madeline

Medical Fetishist

Contact

E-MAIL:
If you have a question that is not covered on my site, feel free to e-mail your inquiry to me. My e-mail address is:


SESSION SCHEDULING:
If you wish to schedule a session, review my website in its entirety, then complete this booking form. All applicants are required to complete this application. No exceptions will be made; no form, no Nurse Madeline, period.

Appointment Application

Ready to schedule an appointment? If so, complete this form in its entirety. The results will be e-mailed to me via this form. I will review them as soon as possible. I will contact you as soon as I have reviewed your application. Incomplete applications will be discarded. All information is kept confidential and destroyed immediately after our appointment. I am well-known for my integrity and high level of discretion. Please, read each question carefully, before you answer.

YOU MUST BOOK AT LEAST 24 HOURS IN ADVANCE, BECAUSE I DO NOT DO SAME DAY APPOINTMENTS WITH NEW CLIENTS.

Applicant Information

Legal Full First Name:

Legal Last Name:

Nickname or Sissy Name:

E-mail:

Daytime Phone:

Evening Phone:

City of residence as it appears on your drivers license or state-issued ID:

State of residence as it appears on your driver's license or state-issued ID:

Residence if you live outside of the US:

Gender:

Occupation:

Birth Month:

Birth Year:
You must be 30-70 years old to visit the Kinky Klinik.

Ethnicity:

Height:

Weight:

Hair Color:


(choose all that apply by holding down ctrl and highlighting choices)

Eye Color:

Disabilities and/or physical anomalies:

Verification Site Information - Leave Blank If Not Applicable

RS2K Info:

Date Check Info:

Preferred411 Info:

Previous Experience Information - Leave Blank If Not Applicable

If you've seen a professional "nurse," escort, or dominatrix before, who did you see most recently? Please, include as much info as possible (her stage name, phone number, e-mail address, website, etc.):

Appointment Information

Appointment Date Desired:

Appointment Type Desired:

In-call

Out-call

Out-call City (Leave blank if you wish to come to the Kinky Klinik near O'Hare airport):

Time Desired:

Morning

Afternoon

Evening

Late Night

Where did you find my website?
(e.g. Max Fisch, Beth Tyler, Google, Yahoo!, etc.):

Comments:




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If you do not hear from me within 24 hours of submitting this form, please e-mail me.

Vintage Enema Illustrations

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