INFORMED CONSENT FOR TREATMENT WITH RADIESSE FILLER

Information Form


POSSIBLE SIDE EFFECTS AND COMPLICATIONS


The possible side effects are similar to those of other absorbable fillers: minor bleeding or bruising due to the needle, swelling, and numbness. These effects are the most common and disappear within a few hours or a few days. Rare effects include inflammation and hardening in the treated areas. If you suffer from diseases involving poor wound healing, a delay in healing may occur. If side effects are observed in the treated area that last longer than one week, the doctor must be informed.


When to avoid treatment with Radiesse:


- If you have an allergy to any of the excipients.


- If you have a predisposition to developing keloids or granulomas.


- If your skin is inflamed or infected.


- If you have permanent implants in the area to be treated.


 


Please inform your doctor before treatment if you are taking anticoagulants, or if you suffer from a systemic disease (autoimmune diseases, diabetes, rheumatism, or endocarditis). Pregnant women, breastfeeding mothers, or adolescents under 18 years of age should not be treated.


THE INJECTION PROCEDURE


Treatment with Radiesse usually takes only a few minutes. Radiesse is injected with a very fine needle under the wrinkle or into the area affected by volume loss. In most patients, the improvement is immediately visible. The improvement depends on the depth of the wrinkle to be treated or the amount of volume to be recreated.


Slight bleeding may occur during the injection, which will disappear immediately after treatment. Occasionally, the injection site may cause minor bruising or hardening, but this effect generally disappears after a short period of time (from a few hours to a few days).


Once the filler is implanted, the doctor will massage the treated area to shape and model the product for an optimal result. The effects of the treatment are long-lasting but not permanent, due to the natural biodegradation process of the product.


WHAT ELSE YOU NEED TO KEEP IN MIND


Please inform your doctor about any existing illnesses at the time of treatment or before, or in case of previous aesthetic treatments or related complications.


After the treatment, it is advisable to keep the skin rested and applying make-up is not recommended for at least 1 hour. Swelling can be prevented or alleviated with cold compresses or dry ice.


Do not use saunas or Turkish baths for at least 2 weeks after treatment. Please avoid sun exposure, UV rays, and temperatures below 0°C. Do not apply any pressure to the treated areas so that the product can integrate best with the tissue. If palpable nodules are felt, the areas can be massaged to distribute the product.

Si prega di rispondere completamente alle seguenti domande in modo che il medico possa considerare eventuali rischi durante la fase di consulto. Se ha domande, non esiti a chiedere al suo medico.

Clinical questionnaire

I have answered all questions to the best of my knowledge.
Patient consent
I have read this document in its entirety and agree to be treated with Radiesse. The injection technique and indications for treatment, as well as the treatment's prospects for success, were explained to me in detail during the pre-treatment consultation. I was informed of contraindications and side effects. I had the opportunity to ask questions and received all necessary explanations. I also received written information and was given sufficient time to make my decision.
I answered questions about my medical history to the best of my knowledge. I was informed that the duration of the filler effect varies depending on skin type and predisposition. A post-treatment check-up appointment was scheduled. A follow-up treatment is recommended after 12-15 months.

If any adjustments or modifications to the treatment plan are deemed necessary, I agree to take the necessary steps to optimize the results.

GENERAL INFORMATION ON THE PROCESSING OF PERSONAL DATA
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.

IN FAITH



Clinica Milano – Skin Lab ®

I agree to be legally bound by this consent
and the Electronic Signature Terms of Use.