ALL INFORMATION ENTERED ON THIS FORM IS STRICTLY CONFIDENTIAL.
At Ageless Laser Tattoo Removal we never share nor sell your name or email address.

HELPFUL INFORMATION

Where is your unwanted tattoo located on your body? *
What color is your skin in the area you want to be treated?*
Do you have a sun tan? *
What is your skin type in the area you are considering to have your tattoo removed?*
Have you been on the drug Accutane in the past 6 months?*
How long you have had this tattoo? Also list any other concerns.*

PERSONAL INFORMATION

Please fill in the appropriate information for better service. All Information entered here is Strictly Confidential!

Would you like us to call you to discuss your needs? *
Would you like a free tattoo removal brochure mailed to you?*
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What e-mail address would you like the analysis results sent to?*

Your E-mail must be provided to receive information.

Required fields are marked with an *. Please make sure that all the required fields are filled out. Thank you! We will respond to your request within 24 hours.

Submit a picture of your tattoo for a quick & easy evaluation (Optional)

Please call (954) 680-8330 to setup a free consultation with me to understand more about the PiQo4 and the laser tattoo removal process.