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.

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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