INFORMED CONSENT FOR TREATMENT WITH DERMAMELAN

Clinica Milano – Skin Lab® explained the characteristics of the Dermamelan® treatment to me.

1 – The purpose of this technique is to remove the outer layers of the skin to stimulate cell renewal and ultimately achieve an even complexion and/or the elimination of melasma.
2 – The treatment consists of eliminating the outer layers of the skin through the application of chemical agents, creating a slight burn and subsequent re-epithelialization. Different acids, such as mandelic, glycolic, or lactic, can be used.
3 – My doctor explained to me that, for best results, it is necessary to strictly follow the treatment both in the doctor's office and at home.
4 – I understand that despite a thorough medical history and proper treatment, side effects may occur, such as mild discomfort, itching, superficial peeling, erythema,
acne eruptions, hyper- or hypopigmentation in the treated area.

The doctor also informed me that the final results also depend on adherence to the home treatment program, which involves applying Hydra-Vital Factor K as prescribed for a minimum of 6 months. This is to restore the skin's hydrolipidic film.

My medical conditions are important and crucial to the success of the treatment, so I informed the doctor of any of my:

- Allergies
- Medications
- Current herpes simplex 1 infections
- Tendency to form keloids

I declare that

I am not pregnant.

I declare that

I have disclosed without reservations my health status and any current pharmacological therapies to allow the doctor to evaluate any contraindications or specific incidences of complications and side effects.

I declare that

I am of legal age 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 I received.

SIGNATURE OF THE INFORMATION NOTICE

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

To this end, I DECLARE

That I have received from Clinica Milano – Skin Lab ® extensive, complete, and comprehensive explanations regarding the information summarized in this information notice, and that I have no other questions or doubts regarding the treatment covered by this consent form (a copy of which I may request), having therefore understood all the elements necessary to make a free and informed decision regarding the treatment.

INFORMED CONSENT OBTAINED FOR DERMAMELAN TREATMENT

In the doctor-patient relationship, it is essential and ethically correct that the patient assume a conscious and participatory role in the treatment and diagnostic tests they voluntarily undertake, as 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 explained 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 treatment protocol, my clinical situation and related diagnosis, the therapeutic options, benefits, limitations, alternatives, possible side effects, and the pre- and post-treatment indications and procedures I will need to follow to achieve the desired result, 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 exhaustive. In particular, I am aware of having been informed about my clinical situation and related diagnosis, the therapeutic options, benefits, limitations, alternatives, possible side effects, complications and outcomes, pre- and post-treatment indications and procedures, as well as the frequency and repetitiveness of the treatment. In particular, I fully understand the summary of the doctor's explanation.

I AGREE

Therefore, without reservation, to treatment with Dermamelan

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.