Where is your unwanted tattoo located on your body? *

What color is your skin in the area you want to be treated?*
WhiteBrownBlackLight Brown

Do you have a sun tan? *
TanSlight TanNo Tan

What is your skin type in the area you are considering to have your tattoo removed?*
Type I- Always burn, never tan (extremely fair skin/blond hair/blue/green eyes)Type II- Usually burn, tan less than about average (fair skin, sandy brown to brown hair, green/blue eyes)Type III- Sometimes mild burn, tan about average (medium skin, brown hair, green/brown eyes)Type IV- Rarely burn, tan more than average (olive skin, brown/black hair, dark brown/black eyes)Type V- Moderately pigmented, tans profusely (dark brown skin, black hair, black eyes)Type VI-Deeply pigmented, never burns (black skin, black hair, black eyes)

Have you been on the drug Accutane in the past 6 months?*
YesNo

How long you have had this tattoo? Also list any other concerns.*

Would you like us to call you to discuss your needs? *
YesNo

Would you like a free tattoo removal brochure mailed to you?*
YesNo

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.

Disclaimer: By submitting this form you allow AGELESS MEDICAL to provide you with more information using texting, email or phone contact.