Skippy Consent Form

In partnership with your child’s school, Tri-County Health Network (TCHNetwork) is pleased to offer Skippy+, a school based dental program providing comprehensive dental care to your child. Our services bring dental care to your child so that she/he can spend more time in the classroom and less time traveling to a dentist!

The preventive dental visit takes about 30 minutes and gets your child back in the classroom quickly.

Please review the following information before completing the consent form on the next page. 

Services Provided:

If you agree to have your child participate in Skippy+, our dental team will provide:

  • Comprehensive Dental Exam
  • X-Rays
  • Fluoride treatment
  • Protective Sealants
  • Cleaning
  • Free toothbrush, toothpaste and floss
  • Education to your children about how to brush and floss
  • Primary Restorative care: Fillings, Interim Temporary Restorations (ITR) and Silver Diamine Fluroide (SDF), when necessary
  • Health insurance enrollment assistance


  • Skippy is offered at no out of pocket costs to all families
  • If you have dental insurance, we will bill for services just like other dental offices


  • Dental care may have risks that are rare and minimal

Privacy Policy:

  • Information collected in this program will be kept private, unless required by law or to bill your insurance and will be shared only within the Skippy program
  • If your child does not have health insurance. TCHNetwork will contact you to discuss potential health insurance options
  • Participation is voluntary; this consent is valid for the entire school year, both fall and spring semesters, unless revoked by a parent or guardian


  • Ask questions and have them answered to before and after signing the consent form
  • Contact TCHNetwork at 970-708-7096 or email

Interim Therapeutic Restoration Treatment

Benefits of receiving ITR:
• Interim Therapeutic Restoration (ITR) is a temporary filling that will stabilize teeth that have decay until there is further evaluation or treatment by a dentist.
• An ITR can prevent more decay or slow down tooth decay.

Summary of ITR placement:
• Tooth will be thoroughly cleaned
• Some decay may be left in the tooth
• A filling will be placed in the tooth
• This procedure is generally comfortable and pain free
• No local anesthetic is necessary

Risks of receiving ITR:
• There is a small possibility of feeling pain in the tooth after the procedure, but this should be temporary

Silver Diamine Fluoride Treatment

Facts for Consideration:
• Silver diamine fluoride (SDF) is a safe, non-invasive, FDA approved liquid that helps stop tooth decay.
• SDF treatment is recommended by our partner dentist and applied by a dentist or dental hygienist.
• A small amount of SDF is applied to the tooth area with decay.
• After it is applied the patient should not eat or drink for 60 minutes.
• The decayed area will stain black permanently, but healthy
tooth structure will not stain.

Benefits of Receiving SDF:
• Stops disease quickly
• Do not need to numb teeth
• No pain with application

Risk of Receiving SDF:
• The decayed area will permanently stain black
• Tooth-colored fillings and crowns may become discolored if SDF is applied to them
• A filling or crown may still be needed after the application of SDF
• If SDF is accidentally applied to the skin or gums a brown or white stain may appear that causes no harm. It cannot be washed off but will disappear in one to three weeks.
• Patient should not be treated with SDF if:
     o  The patient is allergic to silver
     o  The patient has painful sores or raw areas on the gum or anywhere in the mouth

Alternatives to SDF:
• Forgo any treatment, which may lead to continued decay and break down of decayed tooth
• Placement of fillings or crowns, extractions or referral to a specialist


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