INFORMED CONSENT FOR HYALURONIC ACID FILLERS TREATMENT

I, the undersigned, declare that I have been fully informed by the doctor regarding the injection of a filler substance into various areas of the face and body. The treatment will be performed with the aid of a medical device, about which I have received detailed information.

The substance that will be injected during the treatment contains hyaluronic acid as its main component. 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. - That bruising, hematoma, and 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. – That localized allergic reactions may occur 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 been described as mild to moderate, self-limiting, and lasting an average of two weeks. In rare cases, these reactions have lasted for several months. In very rare cases (less than one in fifteen thousand patients), permanent hardness, abscess formation, or a grayish discoloration at the implant site has occurred.

These reactions can develop weeks to months after injections and may last several months, but typically resolve over time. – That crusting and tissue detachment (flaking) have been observed in the treatment area, with the possibility of a resulting superficial scar. I understand that the occurrence of the described reactions, complications, or outcomes may result in a reduction in my social activities for a variable period of time.

The doctor provided me with all the information and instructions regarding the precautions and warnings to be taken in the days before and after the treatment to promote normal healing and avoid complications, as well as to ensure the success of the treatment itself. I was 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, in particular: Avoid sun exposure and tanning with UVA lamps after the treatment.

I certify that I have carefully read this document and that I recognize its contents as identical to the information I received orally during my discussions with Dr. 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 treatment. Therefore, I hereby indemnify the doctor against 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 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 understood and that satisfied me. Based on the information and clarifications received, and in full freedom of judgment, I accept the proposed treatment.

I declare that I have disclosed my health status without reservations, to allow the doctor to assess any contraindications or specific incidences of complications and side effects.

I certify that I am an adult or, if I am a minor or a legal guardian, my parents or legal guardian will co-sign this form with me after receiving the same information that was provided to me.

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.