INFORMED CONSENT FOR MEDISCULPT TREATMENT

PATIENT DATA

CONSENT

A series of non-invasive treatments with Medisculpt is available. The device is indicated for improving abdominal tone, strengthening abdominal muscles, developing a firmer abdomen, and strengthening, toning, and firming the buttocks.

Your doctor will discuss your specific treatment needs. The recommended number of treatments is 4-6. Each treatment session typically lasts 30 minutes, with sessions separated by at least two days. Completing a full protocol is necessary to maximize the effectiveness of the treatment. You may require additional treatments depending on your goals.

No special preparation is required before treatment; however, it is recommended to stay well hydrated. On the day of treatment, it is recommended to wear comfortable clothing that allows for proper positioning during treatment. You will be asked to remove all metal accessories and electronic devices.

I acknowledge that the success of the treatment may be affected by smoking or excessive alcohol consumption, as well as: eating disorders or ongoing medication. While no special diet is required, you are encouraged to maintain healthy eating habits to promote and maintain results.

The treatment does not require anesthesia. During the application, you will feel intense muscle contractions in the treated area. The procedure requires no recovery time. You can generally return to your daily routine immediately after treatment.

I understand that the treatment should preferably be performed directly on the skin. Otherwise, I understand that I will not wear any metal accessories (such as jewelry, watches, or clothing containing metal wires) during treatment. Furthermore, I declare that I do not have any metal or electronic implants (such as pacemakers, defibrillators, metal intrauterine devices, etc.).

Please respond if you currently have, or have had in the past, any of the following:

Please answer the following questions:

Treatment considerations

I understand that treatment cannot be performed on the head, heart, and neck.

I understand that pregnancy and breastfeeding are contraindicated, and pregnant women cannot undergo treatment.

I acknowledge that there are certain risks associated with Medisculpt treatments, including, but not limited to, muscle pain, temporary muscle spasm, temporary joint or tendon pain, local erythema or redness of the skin, and decreased intramuscular fat.

I understand that treatment on injured or otherwise compromised muscles is contraindicated.

I acknowledge that treatment may result in known or unknown complications or injuries, and I freely assume these risks.

I consent to photographs, measurements, and weighing before and after treatment, as this will assist physicians in evaluating treatment results. This information will be collected for medical records or marketing purposes.

I understand that results may vary from person to person, and that an exact outcome cannot be predicted. Completing an entire treatment protocol is necessary to maximize the effectiveness of the treatment. It is highly unlikely, but possible, that you will not experience any discernible results after the full protocol. I acknowledge that the results may not meet my expectations.

I certify that I have read this entire document and agree to all provisions. I certify that I have had the opportunity to ask questions and have found the answers fully satisfactory. I fully understand the treatment conditions, the procedure, and the possible side effects.

I certify that I have read and fully understand this informed consent. I voluntarily consent to treatment with Medisculpt by the physician and his designated staff.

My signature below indicates that the above information is accurate and current.

INFORMATION AND CONSENT TO THE PROCESSING OF PERSONAL DATA

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.

TO BE COMPLETED ONLY IN CASE OF MINORS

IN FAITH

Firmato Clinica Milano – Skin Lab ®
I agree to be legally bound by this consent
and the Electronic Signature Terms of Use.