INFORMED CONSENT FOR OXYGEN-OZONE MEDICAL TREATMENT
LAW 22 December 2017, No. 219 - Art. 1 - Paragraph 3.

Everyone has the right to know their health conditions and to be informed in a comprehensive, up-to-date, and understandable manner regarding the diagnosis, prognosis, benefits, and risks of diagnostic tests and recommended medical treatments, as well as possible alternatives and the consequences of refusing or refusing medical treatment and diagnostic tests.

The patient may refuse to receive the information in whole or in part, or designate family members or a trusted person to receive it and to express consent on their behalf, if the patient so wishes. Refusal or refusal to receive information, and any designation of a designated person, are recorded in the patient's medical record and electronic health record.

Paragraph 4. Informed consent, obtained in the manner and with the tools most appropriate to the patient's condition, is documented in writing or through video recordings or, for persons with disabilities, through devices that enable communication. Informed consent, in whatever form expressed, is recorded in the patient's medical record and electronic health record.

Paragraph 5. Every person with legal capacity has the right to refuse, in whole or in part, using the same procedures as those referred to in paragraph 4, any diagnostic test or medical treatment indicated by a physician for their condition, or individual aspects of the treatment itself.

They also have the right to revoke their consent at any time, using the same procedures as those referred to in paragraph 4, even when such revocation would result in the interruption of treatment.

I, THE UNDERSIGNED

I am suffering from one of the conditions treatable with oxygen-ozone therapy. I am aware of the possible therapeutic alternatives and the potential consequences of failure to treat them.

Therefore, I request oxygen-ozone therapy through local and/or systemic administration and declare that my signature on this form only seals the communication process with the healthcare provider treating me, which is much longer and more complete than what is summarized here for brevity.

I declare that I have been fully informed verbally about the diagnosis of the condition I am suffering from, its therapeutic indications, and the treatment I will undergo. I am aware that systemic ozone administration is contraindicated in cases of glucose-6-phosphate dehydrogenase (G6PD) deficiency, known as "favism."

I am aware that systemic ozone administration is not recommended during pregnancy and constitutes doping in competitive sports. I understand that hypotensive episodes have been reported in patients treated with ACE inhibitors, and it is not recommended to take ACE inhibitors on the day of systemic therapy. I understand that patients treated with

Dicumarols must carefully monitor their INR. I understand that patients with a history of epilepsy may experience a seizure concomitantly with the administration of the therapy.

I am aware of the possible side effects, namely, TRANSIENT TACHYCARDIA, TRANSIENT LOCAL PAIN, ECCHIMOSIS AND HEMATOMAS AT THE INJECTION SITE, VAGAL REACTIONS, and the currently known rates of each reported effect.

I understand that the occurrence of certain complications could cause a short-term reduction in my social or work activities.

I have received information regarding the expected treatment and recovery time and the possibility of a prolongation of the prognosis. I understand that I have not been given any guarantee of any specific therapeutic outcome.

I understand that any therapeutic intervention may not be definitive, but only part of a broader process.

I authorize the doctor, if necessary, to modify the planned intervention, in order to achieve the best therapeutic outcome, or to address any pathological conditions that are currently undetectable. I understand that I can withdraw my consent at any point during the therapeutic process.

I have been informed of the capabilities and limitations of the healthcare facility hosting me, as well as the possibility of undergoing this therapy at other facilities. I undertake to scrupulously follow the post-treatment instructions provided to me, understanding that failure to comply with them may jeopardize the desired outcome.

I will also ensure that I attend regular check-ups and inform my doctor of any changes in my clinical condition post-treatment. I understand that any further questions or concerns that may arise will be addressed by the same doctors. In conclusion, after receiving the requested clarifications, I hereby sign this document and, aware that the signatures of the parties constitute informed consent and certification of the facts recounted herein, I specifically declare that:

A) I have understood what the physician has explained and clarified, as summarized above;

B) I accept the risks of the therapy as anticipated;

C) I request to proceed with the treatment itself;

D) I consent to the oxygen-ozone therapy treatment;

E) I have obtained extensive information (e.g., from acquaintances and/or the internet) and have discussed the matter with the doctor, resolving any doubts I may have.

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.