...I don't think it's age. Most provider's don't care about that. There is one I know of that won't see anyone over 55 but she is the only one I'm aware of. When the question comes up every one that has replied says they don't care. There are plenty of guys in their 70's seeing providers. There is a guy here in his 80's. Maybe he'll speak up. I can't recall his name/handle right now.
Many of us are retired. I am. It's not a problem. They can still screen you.
Don't know if you're new to this but I'll continue as if you are.
Do you have references from other providers you have seen and do you include that in the info you put on the form. Are you a member of a verification service (P411, Date Check, RoomService2000). P411 (Preferred 411) is known for working with retired and or self-employed guys to get them verified. Do you give that info to her. Do you have VIP membership here so you can read the reviews to find the provider that provides what you are looking for. If your answer is no to the above look into it. These help when searching for, finding, and scheduling with a provider.
About the form, I won't fill them out. Why? Because of what you have said here. No response. Additionally, I don't know where that info goes. I will gladly give the lady the info she wants in an e-mail but not her web site based form. I have never been turned down for not using the form. I did get no response the one time I filled one out (I was a newbie). Guys post here often saying they get no response when they do the form.
Another suggestion is post an ISO (in search of) post on the Carolinas board and see which ladies respond. There are some good providers that work in the Carolinas.
Read back on this board to see what providers have said when the age question has come up.
Have you tried an escort agency. Their screening is a bit simpler and once you're in you're in. Make sure the agency has a good reputation and check their providers reviews so you get what you want.
Hope this helps.