Floyd's Touch
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The following information helps me to get to know you a bit better as well as a source of information when you return for a repeat appointment. This info is for my eyes only and will not be disclosed or shared in any way. I don't expect any information that will make you uncomfortable, and please know that all info given me is kept strictly confidential and I do not use it to contact you unless you ask me to. If you use any pseudonyms, then please continue to use the same one with me to avoid confusion. Normally the main method of contact is via email, so please give me an email address that is secure and private for you only. All required fields are marked with an *. If there is a required field that you do not feel comfortable filling out, please put "****" in the field and we can discuss it when you are here. Please fill in as many of the fields below as possible. All info is kept confidential and is securely stored only on my website. This info is used to get to know you and to create a session that will be most beneficial and enjoyable for you.
Email *
First Name *
Last Name *
Street Address
City *
State *
Zip
Phone Number *
Date of Birth *
mm/dd/yyyy
Mobile Carrier *
- Select -
us-cellular
rogers
metropcs
cricket
tmobile
sprint
att
verizon
Please make sure that you include the country code. For example, the US number (248) 123-7654 becomes +12481237654, the UK number 07777123456 becomes +447777123456.
Mobile Phone For SMS Notifications
Please make sure that you include the country code. For example, the US number (248) 123-7654 becomes +12481237654, the UK number 07777123456 becomes +447777123456.
What is your type of occupation?
How did you hear about Floydstouch?
If from a website, list which one or the name of the person referring you.
What is your marital status *
Select one below
Single
Single(Divorced)
Single(Widowed)
Relationship with a female
Relationship with a male
What is your spouse/partner's name?
What is your height (feet/inches)
What is your weight?
Have you ever had a massage or bodywork session before? *
Select One
Yes
No
Conditions
Please list any medical, blood, or infectious skin conditions that I should be aware of? (including STDs, HIV, etc)
Enjoy
Areas you generally enjoy having worked the most:
Avoid
Areas to generally avoid or that you don't like having touched:
Preferred Pressure *
Select One
Light
Medium
Heavy
Type of Session *
Select One
Traditional Swedish - relaxing - without release
Taoist - sensual / relaxing - without release
Tantric - sensual / relaxing - with release
Indicate the ONE that you are usually most interested in:
Genital Area *
Select One
Yes
No
Are you comfortable with having your genitals / groin area worked during a Tantric session:
Prostate Manipulation *
Select One
Yes
No
Do you want to have your prostate anally manipulated (either finger or with prostate manipulation tool)
Additonal options
Additional Items that can be included: <Deep Tissue on the areas where I have knots> <Stretching of arms and legs> <Spanking/Discipline> <Flogging> <Restraints> <Blindfold> <E-stim> <Inversion Table> <Cage Time> <Violet Wand> <Submissive Body Inspection (while restrained and blindfolded)> <Hair trimming (back, butt, groin)>
Indicate in the next field which of the above choices might interest you to be included during the session. You are welcome to add any items that you might enjoy and are not on the list.
Request/Comments
Disclaimer
PLEASE READ AND INDICATE YOUR AGREEMENT BELOW: I understand that the bodywork I receive is provided for the basic purpose of relaxation and relief of tension and stress. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and touch may be adjusted to my level of comfort. If at any point during the bodywork session I am uncomfortable with the therapist’s actions or touch, I agree to notify him immediately. Otherwise it will be assumed I am comfortable with his touch. Likewise the therapist has the right to end the session at any time he is uncomfortable with the client’s request. I understand this is a full-body session and all areas of the body will be worked unless otherwise discussed. All manipulations are for therapeutic benefits only. Because bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I forget to do so. I understand that charges for this and all sessions are for the practitioner’s time and not for the services or activities engaged in during the session.
Disclaimer Agreement *
Select One
Yes
No
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