INFORMED CONSENT FOR FRACTIONAL ABLATIVE LASER TREATMENT:
ERBIUM YAG Ipixel 2940 FOR FACE AND BODY

Fractional treatment involves eliminating the targeted skin using a grid of tiny, pinpoint holes that are then replaced by surrounding skin regrowth. The treatment only affects a fraction of the entire surface (hence the name fractional) each time, so the method requires multiple subsequent sessions. The number of sessions varies from 2 to 6 or more, depending on the type and extent of the problem being treated. Improvement is gradual and may be more or less noticeable after each session, depending on the patient's response.

After treatment, tiny brownish crusts form, giving the treated area a stippled or tanned appearance. The crusts typically fall off after 7-10 days, followed by mild redness that gradually diminishes over the following weeks, and sometimes slight swelling of the treated area. After deeper treatments, a temporary burning or itching sensation may occur, associated with the presence of small droplets of serum or, more rarely, blood.

As a result of skin renewal, you may experience increases or decreases in skin color, which are usually temporary but rarely permanent. Only in cases of abnormal skin reactivity may scarring occur.

In the days following treatment, it is necessary to follow the doctor's instructions and avoid exposing the treated areas to the sun.

I declare that I have not previously experienced any such occurrences as a result of medical treatments or accidental events.

I understand that, given the individual variability of response to any medical-surgical treatment, there can be no certainty of results, nor can the percentage of improvement be precisely predicted.

I have been informed that by not undergoing the treatment, I would not expose myself to any risk, and I have been explained reasonable alternatives to the treatment.

I authorize the collection of photographic documentation, which will remain the property of the healthcare professional for clinical archiving purposes. This documentation may be used anonymously for the purposes of research, education, or dissemination in the medical field.

I agree to undergo the therapies and check-ups prescribed for me in the period following the treatment, having been informed that failure to do so could compromise the outcome of the procedure. Any post-treatment medications or check-ups performed by another professional will automatically exonerate the operator from any liability.

I acknowledge that this treatment is subject to a fee and that I have been informed of the related cost.

I declare that I have been fully informed of the nature and purpose of the procedure, the expected results, and possible complications, and I understand that no guarantee can be given regarding the final outcome. I am fully aware that my interest is aesthetic and that the decision to proceed is based solely on my own volition.

After receiving all the explanations I requested, I agree to undergo the above-mentioned treatment, expressing my consent on this form, which I have had the opportunity to read and understand in advance.

The client acknowledges that the sessions included in the purchased treatment/package may be cancelled by email with no less than 24 hours' notice, given the facility's need to organize its internal operations. Therefore, if notice is not given, the treatment cannot be rescheduled, and the client expressly accepts the right to retain the corresponding amounts as a penalty.

The client, also pursuant to Article 1341 of the Italian Civil Code, accepts the penalty clause regarding the withholding of amounts for booked treatments not cancelled within 24 hours of the same.

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.