INFORMED CONSENT FOR CHEMICAL PEELING

INFORMED CONSENT FORM FOR CHEMICAL PEEL TREATMENT
In view of the medical treatment to be carried out by Clinica Milano – Skin Lab ® through CHEMICAL PEELING, I, the undersigned, hereby confirm that I have been fully informed about the nature and known effects of the treatment, which is summarized below for clarity.

Consent is personal and non-delegable to third parties (except for minors or subjects under guardianship). In the relationship between doctor and patient, an aware and active role of the latter is considered necessary and ethically correct in relation to the treatment and diagnostic tests to which they voluntarily submit.

For this reason, you are being informed with this document, and the doctor who submits and simultaneously illustrates it to you will provide you with all the necessary, clear, and comprehensive information for your understanding and will ascertain that you have fully understood what is being submitted here for your attention and final signature.

It is important that you consider the explanations provided to be exhaustive and clear, and in particular that you are fully aware of what is being proposed to you in order to obtain an appropriate therapeutic treatment.

Therefore, the benefits in relation to what will be performed on you, the possible risks, and any alternatives will be indicated below, thus allowing you a voluntary and informed decision on the matter. For this purpose, you are also provided with information in writing, as detailed and complete as possible, to make the explanation comprehensible and exhaustive.

In particular, it has been explained to me that the chemical peeling technique consists of the application of an acid, chosen by the doctor according to the desired outcome, which will have a chemical action on the skin that will damage its superficial layer to remove the part to be renewed or re-qualified, resulting in a stimulus for repair and restructuring, actively participating in the renewal of the skin layer in its totality; it is performed with the purpose of removing the stratum corneum of the epidermis to make the skin smoother, eliminate or attenuate small irregularities or skin dyschromia, have a stimulating effect on the fibroblast to improve the appearance of the skin (skin rejuvenation), it can be useful in regulating sebum and therefore find indication in the prevention and treatment of seborrheic and acne-prone skin, and more specifically it can be used with targeted and localized peels for the removal of skin spots (chloasma-melasma, lentigo, keratosis, etc.).

Having taken note of the above, I confirm that the doctor has explained the nature of the treatment and the method by which it is performed, the clinical issues justifying its execution, the risks associated with it, and the possible alternatives.

I have been specifically informed that chemical peeling can induce herpetic recurrences in predisposed individuals, for which prophylactic treatment with antiviral drugs is indicated.

I have been made aware that in the days following the treatment I will have erythema and edema, and from the second to the tenth day after the peel, I may experience intense desquamation with areas of hyperpigmentation. These effects could be more pronounced or last for a longer period than described above.

I therefore commit myself from now on to strictly follow all the pre- and post-peel instructions provided to me, as I understand their importance for achieving the results. I have declared my state of health without reservation to allow the doctor to evaluate any contraindications to the treatment.

Furthermore, I have been informed that this procedure may entail risks or complications due to causes not inherent to the doctor's proper work and that no precise guarantees regarding the result I will achieve with this treatment have been provided to me.

In particular, I have been strongly advised against exposure to ultraviolet rays (sun exposure, sunbeds) as well as heat (very hot showers, saunas, and Turkish baths) or intense cold for the four weeks following the treatment. Similarly, all traumatic maneuvers (rubbing the treated area, scrubs, brushing, aesthetic therapies, etc.) and the use of unsuitable cleansers or cosmetics that may increase the risk of side effects and alter the planned therapeutic result are to be avoided. Furthermore, the consumption of significant quantities of alcoholic beverages and spirits is advised against for a period of 10-14 days.

I have been informed of my skin characteristics and my assigned phototype, and the relative precautions I must take before and after the treatment. I have been informed of the possible need to repeat the treatments to achieve the desired therapeutic result.

I have been informed of alternative procedures, their advantages and disadvantages, risks, and benefits, and I am aware that I have refused them.

Having read the above, and having deemed that I have correctly understood it and obtained the sufficient and necessary clarifications requested during the consultation with the doctor

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.