Child's Personal Information

Child's Health History

PAYMENT INFORMATION - YOU MUST COMPLETE AND SIGN AT BOTTOM

If you have Dental Insurance, Medicaid or CHP+ we will bill for services. If your child currenty receives dental care with a dentist, participation in Skippy is a duplication of those services and can result in denied insurance coverage for dental care.

Consent:
The information on this page and the health history are correct to the best of my knowledge.

I agree and authorize Tri-County Health Network's (TCHNetwork), River Valley Family Health Center’s, and the PIC Place’s licensed dentists and dental hygienists (treating provider) to perform the following dental services as needed:

• 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:
• Interim Temporary Restorations (ITR) – not applicable for Montrose School District
  

  ITRs halt the progression of cavities and provide dental cavity protection. They are used to stabilize dental cavities and prevent them from progressing to cause further decay and disease in a child’s mouth. They do not require local anesthetic, drills, or needles. The dentist uses a glass ionomer that releases fluoride and other minerals on the area that needs treatment, which then reduces the levels of bacteria in the site of decay and halts disease progression until full removal of dental caries is possible. Because glass ionomer and other bioactive materials releases minerals, it helps stimulate the tooth to naturally remineralize. ITRs can be used to treat multiple open carious lesions in a child’s mouth, and typically last from about six months to two years.

• Silver Diamine Fluoride (SDF)
  

  SDF is a liquid antibiotic that can be applied to teeth with certain kinds of cavities or sensitivity. SDF kills the bacteria causing the cavity and strengthens that part of the tooth. It makes the cavity hard like concrete so the cavity does not get bigger and the tooth becomes less sensitive. Using SDF “buys time” to fix the cavities – especially if your child is young or anxious and cannot cooperate for fillings or crowns.

  This medicine will stain the cavity dark black. The healthy parts of the tooth will not be stained. The black color indicates that the SDF is working. Stained areas can later be covered with fillings or crowns

  
• Health insurance enrollment assistance

I further understand that for the sustainability of the program, my insurance will be billed, if applicable. I request and authorize the release of any information on this form and acquired during treatment for payment and referral purpose as deemed necessary by treating provider. I also authorize treating provider to submit claims to my insurance company on my behalf, and my insurance company to pay benefits directly to TCHNetwork, as applicable. Should any insurance payment be made directly to the insured for monies due on this account, I agree to immediately pay over these funds to treating provider.

Electronic Signature Agreement:
The parties agree that this agreement may be electronically signed. The parties acknowledge that electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability and admissibility.

Release of Information Consent
By signing this application, I understand that my information may include protected health information. I authorize the release of my information to any person or agency necessary to meet my service needs, including, but not limited to, vendors and partner agencies. This information will be used solely for the purpose of assessing, arranging, and meeting my individual service needs. I release Tri-County Health Network and its partners from any liability related to the sharing of this information.