Skippy+ English 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.

TCHNetwork has been providing Skippy for more than 10 years in schools throughout Montrose, Ouray, Delta and San Miguel counties. We have held over 100 dental clinics, providing more than 7,000 treatments to local children.

Skippy+ is effective! Skippy+ has reduced the percentage of children with untreated decay to 20%, 9% below the national average.

Services Provided:

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

  • Cleaning
  • Exam by a Dentist
  • X-Rays
  • Fluoride treatment
  • Protective Sealants and Interim Temporary Restorations (ITR), when necessary
  • Free toothbrush, toothpaste and floss
  • Take home form about child’s oral health
  • Education to your children how to brush and floss
  • Referrals for any needed follow-up/restorative care (i.e. filings) (additional consent required)
  • Forwarding your child’s records/x-rays to your dentist of choice
  • Health insurance enrollment assistance

Cost:

  • 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 but you will not be billed for any outstanding fees

Risk:

  • The materials used, and dental care provided, are the same as those in dental offices
  • Dental care may have risks that are rare and minimal
  • Dental hygienists provide the care in partnership with a dentist who follows standard dental procedures that include wearing latex free gloves, facemasks, sanitation and eye shields

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 Navigators will contact you to discuss potential health insurance options

Withdrawal:

  • Participation is voluntary; your child does not have to participate in Skippy+ and can be revoked at any time by calling 970-708-7096
  • This consent is valid for the entire school year, both fall and spring semesters, unless revoked

Rights:

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

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