Appointment Request Form
Thanks for your interest in booking a date with me!
I know this part is tedious, but after this we can have the time of our lives together.
  • / /
  • Verification

    For the comfort and safety of everyone involved, screening is REQUIRED. Rest assured that I am a discreet provider and that any information exchanged between us is destroyed immediately after your screening process is complete.

    I require either employment verification, or at least two provider references. Providers must have been seen by you within the last 12 months.

    Whichever method you choose, please fill out the options thoroughly and completely. The more information you provide, the easier you are to screen. The easier you are to screen, the sooner we can see each other!
  • Employment Verification

    Please provide a valid company e-mail address (@gmail, @yahoo, @aol, etc are invalid). You will be sent a 6-digit verification code from a discreet, unlisted e-mail account with no affiliation to Marina DuBois. Once received, send it back to me via e-mail at marinadubois@zoho.com .
  • Provider References

  • Appointment Details

  • / /
  • :
  • Juicy Details

    Questions, comments, concerns? Looking for something special? Want to tell me something I should know about you? Do it in this nifty little box.

    But please, do be a gentleman: any reference to donations, fees, or anything lewd and crude means you won't hear back from me. :'( Thanks for respecting these communication boundaries. I can't wait to hear from you! xo
Powered byEMF Form Builder
Report Abuse