Note: . Instagram accounts. Pictures without consent forms will not

May 1st is Doctors’ Day in Ontario, and HSN would like to honour all physicians for their
dedication and compassionate care of patients, including the 350+ who provide care at HSN.
Join us in celebrating and thanking them for all the work they do to help patients in our
community. Here is how you can say thank you to your doctor:
1.
Print the next two pages (page 2 and 3).
2.
Write your doctor’s name on the Doctors’ Day 2017 Thank You sheet and then get
someone to snap a picture of you holding the sign. Make sure not to include any patient
or confidential information on the Thank You sheet or in the background of the photo.
3.
Print, complete, sign and scan the Consent Form.
Note:
a) IMPORTANT: If you are submitting a picture that includes a minor (under 16 years
of age), a parent or guardian must sign the consent form.
b) If you do not have access to a scanner, you can take a photo of the completed
consent form and submit it with the Doctors’ Day 2017 picture.
4.
Send the picture, message and completed consent form to
st
[email protected] by 4PM on Friday, April 21 .
Remember to include the reason you appreciate your doctor. We will use this as the
photo caption for the post.
Submissions will be posted on HSN’s Facebook page and will be shared on HSN’s Twitter and
Instagram accounts. Pictures without consent forms will not be included in the
Doctors’ Day 2017 celebrations.
Thank ou
From the bottom of our
Event / Activité
Doctors' Day 2017 / Journée des médecins 2017
Consent and Release
Consentement et décharge de responsabilité
In consideration of Health Sciences North’s (HSN)
role to provide patient centered health services to
the community, I,
En considération du rôle d’Horizon Santé-Nord
(HSN) à fournir à la communauté des services de
santé centrés sur les patients, par la présente, je :
(Patient Name and/or Parent/Guardian Name)
(Nom de la patiente ou du patient et/ou du parent ou de la tutrice ou du tuteur)
*Note: If signed as parent or guardian of a minor (16 years or less), the relationship should be noted.
* Remarque : Si la signature est celle d’un parent ou d’un tuteur d’une personne mineure (16 ans ou moins), le lien de parenté doit être
indiqué.
hereby:
a) Grant permission to HSN or anyone it may
designate to take and produce photographs,
films, sound recordings and any other audio
and/or visual reproduction including media
and promotional videos for use in
advertising, promotion or publicity of HSN,
including, but not limited to print media,
social media and online content which may
include the use of names;
b) Release and forever discharge HSN, its
officers, directors, trustees, employees and
volunteers from any and all liability, loss,
damage or claims resulting from any
audio/visual materials taken and used; and
c) Understand that my consent can be
withdrawn at any time upon 30 days written
notice addressed to HSN Corporate
Communications Department. HSN therein
reserves the right to continue using
publications previously produced prior to
withdrawn consent.
(a) permet à HSN et à toute personne autorisée
par lui de prendre et de réaliser des
photographies, des films, des
enregistrements sonores et toute autre
reproduction audio et/ou visuelle, y compris
des vidéos médiatiques et promotionnelles à
utiliser à des fins de publicité, de promotion
ou d’annonce concernant HSN, notamment
pour les médias imprimés, les médias
sociaux et la publication en ligne pouvant
comporter l’utilisation de noms;
(b) décharge à tout jamais HSN, ses dirigeants,
les membres de son conseil
d’administration, ses administrateurs, ses
employés et ses bénévoles à l’égard de
toute responsabilité, perte, dommage ou
réclamation découlant de tout document
sonore ou vidéo réalisé et utilisé; et
(c) comprends que mon consentement peut
être retiré en tout temps sur avis écrit de 30
jours adressé au Service des
communications organisationnelles d’HSN.
À cet égard, HSN se réserve le droit de
continuer à utiliser des documents déjà
préparés avant le retrait du consentement.
_______________________________________________________________
Date
________________________________________________________________
Signature
________________________________________________________________
Witness / Témoin