INFORMED CONSENT FOR BIOREVITALIZATION TREATMENT

The treatment will be performed with the injection of a specific medical device.

The substance injected during the treatment contains hyaluronic acid, an acidic, hypertonic amino acid solution. The choice of treatment and type of medical device was agreed upon after careful and thorough information regarding pre-treatment conditions and therapeutic alternatives. I have been informed:

– That the injected substance is resorbable; therefore, the outcome of the treatment will be temporary. The outcome of the treatment and the related protocol may vary from patient to patient. Reactions such as erythema, edema, pain, itching, discoloration, or hyperesthesia may develop at the injection site; these reactions have been described as mild to moderate and generally resolve spontaneously some time after the injection.

Approximately 2% of patients treated with the have experienced localized allergic reactions after one or more injections, including swelling and hardness in the implant area, sometimes extending to surrounding tissue.

Inflammation, infection, and, more rarely, acne-like pustules may result from treatment. These reactions have occurred a few days after the injection or after a few weeks and have been described as mild to moderate, self-limiting, and lasting an average of two weeks. In rare cases, these reactions have persisted for several months. My doctor has provided me with detailed information and instructions regarding the precautions and warnings to be used in the days before and after treatment to promote normal healing and avoid complications, as well as to avoid compromising the success of the treatment itself.

I have been informed that ignoring these precautions and warnings could jeopardize the outcome of the treatment. In this regard, I will strictly follow all instructions given to me during and after treatment.

I certify that I have received all the information and clarifications requested regarding the treatment and that I fully understand its purposes, complications, risks, and possible outcomes. I recognize that the exact outcome cannot be predicted in advance, and in this regard, I declare that the doctor has given me no commitment or guarantee of a specific outcome after the treatment. Therefore, I hereby indemnify the doctor for any failure to achieve the desired aesthetic improvement.

I am aware that the percentage of improvement in the defect to be corrected, its extent, the tolerability of the substance and its duration, and the symmetry of the result depend not only on the techniques employed and the filler used, but even more so on the body's responses.

I certify that I have obtained all necessary and comprehensive clarifications regarding the information contained in this form, that I have asked all the questions I deemed appropriate, and that I have received clear and comprehensive answers that I fully understood and that satisfied me. Based on the information and clarifications received, and with full freedom of judgment, I accept the proposed treatment.

Pursuant to Articles 13 and 14 of EU Regulation No. 2016/679 (the "Regulation") and the provisions of Legislative Decree No. 101/18 (the "Legislative Decree") concerning the protection of natural persons with regard to the processing of personal data, I hereby inform you that the personal data you provide and acquired by Clinica Milano – Skin Lab ® will be processed in compliance with the provisions of the aforementioned Regulation and Legislative Decree. Furthermore, the following is specified:

1. Purpose of processing

The processing of your personal data is solely for the proper performance of aesthetic medicine, prevention, diagnosis, treatment, rehabilitation, or other pharmaceutical and/or specialist services requested by you.

2. Methods of Processing Personal Data

Processing is carried out through operations performed on paper or with the aid of IT tools, or via apps and cloud platforms, and consists of the collection, recording, organization, storage, consultation, processing, modification, selection, extraction, comparison, use, interconnection, blocking, communication, deletion, and destruction of such data. Sometimes, it may be necessary to send data electronically via email, which will be encrypted and password-protected. Processing is carried out by the data controller and by persons expressly authorized by the data controller.

3. Provision of Data and Refusal

The provision of general, sensitive, genetic, and health-related personal data is necessary for the performance of the activities required for prevention, diagnosis, treatment, rehabilitation, or other pharmaceutical and/or specialist services requested by you. Your refusal to provide personal data will make it impossible to perform these activities.

4. Data Disclosure

The personal data collected will not be disclosed. The data will not be shared with third parties, except when necessary and/or required by law and/or for tax compliance. The data will be disclosed only to healthcare personnel at the facility where Clinica Milano – Skin Lab® operates and, where necessary, to physicians, analysis laboratories, medical specialists, hospitals, and consultants—lawyers and/or accountants—used by Clinica Milano – Skin Lab®.


5. Data Retention

Your personal data will be retained for the time strictly necessary for medical care and, in any case, for no longer than ten years. Even when computers are used, appropriate protection measures are adopted to ensure the correct storage and use of data, including by medical practice staff, in compliance with professional secrecy. Professionals and facilities that may have access to such data as a result of the healthcare services provided by Clinica Milano – Skin Lab ® are also required to observe these safeguards.

6. Data Controller

The data controller is Clinica Milano – Skin Lab ®, Via Cerva, 22 – 20122 Milan – SEM s.r.l. | VAT No. 11055590969

7. Rights of the Data Subject

The data subject has the right:

• to request from the data controller access to, rectification or erasure of, or restriction of processing of, personal data, or to object to processing, as well as the right to data portability;
• to receive, in a structured, commonly used, and machine-readable format, the personal data concerning him or her, which he or she has provided to a data controller, and has the right to transmit those data to another data controller without hindrance from the data controller to which the personal data have been provided;
• to withdraw consent at any time, without affecting the lawfulness of processing based on consent before its withdrawal;
• to lodge a complaint with the Italian Data Protection Authority.

The aforementioned rights may be exercised by written communication sent via certified email to semsrl1@pec.it or by registered mail with return receipt to Via Cerva, 22 – 20122 Milan.

With reference to the images (photos and/or videos) taken and/or filmed by Clinica Milano – Skin Lab ®, which are essential for developing your treatment plan and managing diagnoses and future assessments, you authorize, free of charge and without time limits, also pursuant to Article 10 of the Italian Civil Code and Articles 96 and 97 of Law No. 633 of April 22, 1941 (Copyright Law), the storage in your medical records in paper format or with the aid of IT tools or via apps and platforms that use the Cloud, and the possible publication and/or dissemination of your images in any form on the Clinica Milano – Skin Lab ® website or on its social media profiles such as Instagram or Facebook. I also authorize the storage of these photos and videos in the electronic archives of Clinica Milano – Skin Lab®, confirming that the purpose of such publications is purely for informational and educational purposes regarding the professional activities carried out by Clinica Milano – Skin Lab®. This authorization may be revoked at any time by written notice sent by registered mail or certified email.

The undersigned declares that he or she has read the above information, accepts all of its provisions, and consents to the processing of his or her personal data for the purposes, terms, and conditions set forth above.