Required fields are marked with an *.

* 1. Where is your unwanted tattoo located on your body?





 
 
* 2. What color is your skin in the area you want to be treated?

White Brown Black Light Brown

* 3. Do you have a sun tan?

Tan Slight Tan No Tan

* 4. 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)


* 5. Have you been on Accutane in the past 6 months?

Yes No

* 6. Are you currently on any medication?

Yes No

 

* 7. List all colors in your unwanted tattoo?

* 8. How long you have had this tattoo? Also list any other concerns.
* 9.) Personal information. Please fill in the appropriate information for better service. All Information is Strictly Confidential!

* Name

*Address

* City

* State


* Zip Code/ Postal Code


* Phone Number


* Would you like us to call you? (strictly confidential)
Yes No

* Would you like a free tattoo removal brochure mailed to you?
Yes No
* 10. What e-mail address would you like the analysis results sent to? E-mail must be provided to receive information!






Required fields are marked with an *.  Make sure that all the required fields are filled out. Thank you.
We will respond to your request via e-mail.