Jotform Sandbox

We will be reaching out to you within one business day to discuss supports and services.

If you have any questions please contact Amy Rowan at oc-montrose@tchnetwork.org or 970.614.7311 M-F 8-5.

Thank you!

Thank you for submitting the Adult Dental Clinic Registration!

Please click HERE to schedule your appointment.

If you have not already done so, please complete the pre-appointment COVID Symptom Checker. You will complete this checker 3 times – once prior to your appointment, once in the office on the day of your appointment, and once following your appointment.

If you have questions or concerns please contact the TCHNetwork Main Office at (970) 708-7096. Thank you!

Thank you for submitting your COVID Symptom Checker.  Please remember that you must complete this checker 3 times – once a week prior to your appointment, once in the office on the day of your appointment, and once a week afterward.  

Thank you for your request. We will be reaching out to you within one business day to discuss supports and services.

If you have any questions, please contact Hope Logan at oc-sanmiguel@tchnetwork.org or 970.239.1038 M-F 8-5.

Thank you for submitting a volunteer request on behalf of your organization.

We will get back to you as soon as we can. If you have any questions, concerns, or changes to your form – please contact Sami Damsky volunteer@tchnetwork.org or 704.236.4425

Thank you for contacting the Good Neighbor Fund.
We received your application and will be contacting you if we have any questions.
This crisis has caused a lot of uncertainty and financial struggles.
Hopefully the Good Neighbor Fund will be able to support you in this time of need.

Please check the email account that you provided to us in your application for an email from us with additional information.

Stay well,
TCHNetwork

Gracias!

Gracias por contactando el Fondo del Buen Vecino.
Nosotros recibimos su aplicación y nos contactaremos con usted si tenemos algunas preguntas.
Esta crisis ha causado mucha incertidumbre y lucha financiera.
Ojalá el Fondo del Buen Vecino lo podrá apoyar en este tiempo de necesidad.

Por favor, compruebe la cuenta de correo electrónico que nos proporciono en su solicitud para un correo electrónico de nosotros con información adicional.

Manténgase bien
TCHNetwork

Thank you for sharing your support!  Resources like yours are a vital part of keeping our community strong!

Your form has been submitted and Tri-County Health Network will contact you if any additional information is needed.

Your form has been submitted.

Tri-County Health Network will contact you as soon as possible with information on your request.

Thank You!

Your form has been submitted. 

Tri-County Health Network will contact you soon with information on how you can help.

The next class will be held in late April or early May. Once scheduled, we will contact you to give you first dibs on registration, prior to opening it up to the general public.

If you have questions, please call us as at 970-708-7096.

Thank you! Your form has been successfully submitted!
Please be sure to complete and submit the following forms (if you have not already done so):

Release of Information
Disclosure Statement
Notice of Privacy Policy
Client Intake Form

When all forms are received, you will be contacted to schedule your appointment.
If you have more questions please contact our office at 970-708-7096 or Julia Johnston at coord-pc@tchnetwork.org

Gracias, su formulario de autorización médica ha sido completado con éxito.

Sus archivos serán procesados y enviados directamente al proveedor indicado.

Thank you, your medical release form has been successfully completed.

Your files will be processed within two business days and sent directly to the indicated provider.

Su formulario de consentimiento ha sido entregado con éxito,

y un correo de confirmación ha sido enviado.

Si no ve el email en sus correos recibidos, chequee sus carpetas de “Junk” o “Spam”

¡Gracias!

Your Skippy consent form has been successfully submitted.

A confirmation email has been sent.

If you do not see the email in your inbox, check your “Junk” or “Spam” folder.

Spaces are limited to 50 appointments. Please understand that though every child is invited to register for Skippy, if your child received dental care in the past six months, they are not eligible to participate in the program this Spring as services would be duplicative.

In that situation you may be charged for services. We will let you know if your child is enrolled for the Spring clinic.

Thank you!