INFORMED CONSENT FOR NIR TREATMENT

It involves the direct application of infrared waves at varying intensities, producing subcutaneous heat with the aim of reshaping the connective tissue structure, resulting in the smoothing of superficial wrinkles. It also has a restructuring effect on tissue and reactivates microcirculation.

It should not be performed in cases of suspected or confirmed pregnancy, the presence of a pacemaker, cardiac arrhythmia, the presence of metallic materials near the treated tissues, the presence of epileptic seizures, even if mild, or current skin infections or dermatoses. I have informed my doctor of my medical conditions, current drug therapy, and previous therapies for the same condition, and I declare that I will also inform him of any further changes during the course of treatment.

I certify that the doctor has thoroughly provided all the information and instructions regarding the precautions and warnings to be taken in the days before and after the treatment to avoid complications, as well as to avoid side effects (erythema lasting a few hours) that could jeopardize the success of the treatment. I have been informed that failure to follow 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 the treatment. I agree to undergo the therapies and check-ups prescribed in the period following the treatment, having been informed that failure to do so could jeopardize the outcome of the procedure. I understand that the percentage of improvement in the defect to be corrected, the efficacy, tolerability, and duration of the treatment's effects are directly proportional to the nature and complexity of the aesthetic problem, and the achievement of the desired result depends, in any case, on subjective factors. I have been informed that by not undergoing the treatment, I would not expose myself to any risk and that, with the same expected clinical results and no side effects, there are no reasonable alternative treatments. I have carefully read this document and acknowledge its contents.

I declare that I have obtained all necessary and exhaustive clarifications on the information contained in this form, that I have asked all questions I deemed appropriate, and that I have received clear and comprehensive answers that I fully understand and that have satisfied me.

After receiving all the information and clarifications requested regarding the treatment and having fully understood its purposes, complications, risks, and possible outcomes, in full freedom of judgment, by expressing my consent on this form, which I have had the opportunity to read and understand thoroughly beforehand, I authorize the proposed and above-described treatment to be performed.

With reference to the images (photos and videos) taken and/or filmed by the Clinica Milano – Skin Lab ® , essential for drawing up your treatment plan and for managing diagnoses and future assessments, you hereby AUTHORIZE, free of charge, without time limits, also pursuant to articles 10 and 320 of the Italian Civil Code and articles 96 and 97 of Law 22.4.1941, n. 633, Copyright Law, to the storage in the medical records and possible publication and/or diffusion in any form of your images on the website, Facebook page and/or Instagram profile of the Company/Entity/Private individual, as well as on printed paper and/or on any other means of diffusion, as well as authorizing the conservation of the photos and videos themselves in the computer archives of the Clinica Milano – Skin Lab ® and acknowledges that the purpose of such publications is merely for informational and possibly promotional purposes. This release/authorization may be revoked at any time by written notice sent by registered mail or certified email.

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.