INFORMED CONSENT FOR E.A.S.T TREATMENT

I certify that during the examination and discussion with the doctor, I have received adequate information regarding the diagnosis, prognosis, prospects, and possible diagnostic and therapeutic alternatives, as well as the foreseeable consequences of the choices made.

I certify that I have read the following written information on the dos and don'ts, risks, and complications of the most common procedures, and the substances used both in previous procedures and during the treatment in question. Instructions to follow after non-ablative surgical procedures – blepharoplasty, facelift, removal of growths, skin blemishes, pigmentation, scars

1) – The treated area must be washed with water and neutral soap (Marseille soap).

2) – The area must be disinfected daily with a benzalkonium-based disinfectant prescribed by the doctor.

3) – It must not be covered with plasters, due to the possibility of maceration, sensitization, and infection.

4) – No medications or cosmetics should be applied.

5) – The scab must absolutely not be removed due to the risk of dimpling and irregularities in the skin (it will fall off spontaneously after a few days).

6) – The treated area must be protected from ultraviolet radiation (sun, computer monitors, neon and fluorescent lamps, counterfeit detectors, catalysts, etc.) by applying a suitable foundation or other product prescribed by your doctor. Apply the foundation in a one-millimeter layer for as long as the treated skin remains pink after the scab falls off, to prevent the formation of discoloration (this pink color, in predisposed individuals, can last a very long time).

Following blepharoplasty, blepharolift, face and neck lift, and any type of resurfacing, as well as the removal of growths, the following may develop: retracting scars, keloids, skin blemishes, the appearance of capillaries and/or rosacea, allergic reactions due to the disinfectant used, anaphylactic shock-like reactions, and fainting due to emotional autosuggestion or vagal hypertonicity. Following correction of wrinkles, lips, scars, skin depressions, and facial and body volume loss, the following may develop: retracting scars, keloids, skin blemishes, allergic reactions due to the disinfectant used, anaphylactic shock-like reactions, and fainting due to emotional autosuggestion or vagal hypertonicity.

After the removal of telangiectasias and angiomas, dimpling and pigmentation may remain; in some cases, the vessels may reappear in the same location. Following surgical treatment of acne and scarring, significant discoloration, skin retraction, and dimpling may result.

Any type of procedure, even when performed correctly, can cause unpredictable effects given the extreme variability of individual responses. Having understood the information contained herein, explained to me verbally and in writing by the doctor, I agree to undergo the proposed procedure and to pay the fee within the agreed timeframe and amount.

In the doctor-patient relationship, it is necessary and ethically correct for the patient to assume a conscious and participatory role in the treatment and diagnostic tests they voluntarily undergo, as also required by the Code of Medical Ethics.

For this reason, the patient is informed in a comprehensible manner about their problem and/or pathology, is explained the possible treatments, and is given the rationale for choosing the one(s) deemed most suitable to achieve the desired clinical outcome.

It is therefore important that the explanations summarized here and thoroughly illustrated by the doctor are fully understood and deemed comprehensive by the patient.

To this end, I DECLARE

that I have been adequately informed about the therapeutic protocol, the relevant clinical situation and diagnosis, the therapeutic options, benefits, limitations, alternatives, possible side effects, and the indications and procedures I will need to follow pre- and post-treatment to achieve the desired outcome, in order to enable me to make a voluntary and consequently informed decision.

I CONFIRM

that I have fully understood and deemed the information I received from the doctor regarding the treatment I have decided to undergo to be comprehensive. Specifically, I am aware that I have been informed about my clinical situation and the related diagnosis, the therapeutic options, benefits, limitations, alternatives, possible side effects, complications and outcomes, and the pre- and post-treatment indications and procedures.

Having read the above, I believe I have correctly understood it and obtained the requested clarifications, and have had the opportunity to evaluate the risks and benefits of the treatment covered by the information received.

Clinica Milano – Skin Lab ® to perform the medical procedure with E.A.S.T.

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.