Start Evaluation — Fugly Toenails™

Full Name*

First NameLast Name

Email Address*

example@example.com

Phone Number*

What best describes your situation?*

Additional notes / message

Photos of Affected Nail(s)

Upload one or more clear, well-lit photos of the nail(s) or skin area you'd like evaluated. This helps the physician make a more accurate assessment.

LEGAL CONSENT & AUTHORIZATION FOR PERSONAL DATA PROCESSING AND ELECTRONIC COMMUNICATIONS

By submitting this form, I voluntarily authorize Fugly Toenails™ and JAWS Podiatry (Dr. Abraham Wagner, DPM) to collect, store, use, and process my personal and health-related data for purposes of contact, medical evaluation follow-up, treatment coordination, prescription delivery, and information related exclusively to podiatric telemedicine services for the treatment of nail fungus (onychomycosis) and athlete's foot (tinea pedis).

This authorization includes communications via email, phone calls, SMS text messages, WhatsApp, and other electronic or messaging communication channels, strictly related to my medical evaluation, treatment plan, follow-up, and health information relevant to my case.

By providing my phone number and submitting this form, I expressly consent to receive transactional and informational communications (including evaluation results, treatment instructions, prescription updates, follow-up reminders, and health-related information) via SMS, WhatsApp, and similar messaging platforms.

Message frequency may vary. Message and data rates may apply.

I understand that I may opt out of SMS or messaging communications at any time by replying STOP, and request assistance by replying HELP.
I understand that my consent to receive communications is not a condition of receiving medical evaluation or treatment, and that I may withdraw my authorization at any time without affecting the quality of care provided.
I understand that health information shared via electronic communications is subject to HIPAA protections, and that Fugly Toenails™ will implement reasonable safeguards to protect my Protected Health Information (PHI).
I acknowledge that telemedicine consultations do not replace in-person medical care when clinically necessary, and that any treatment prescribed is subject to physician evaluation and discretion.

This consent is granted in accordance with applicable data protection and communication laws, including but not limited to: the TCPA (Telephone Consumer Protection Act), the CAN-SPAM Act, and the CCPA (California Consumer Privacy Act) (United States); HIPAA (Health Insurance Portability and Accountability Act); the Florida Telehealth Act (§456.47, Florida Statutes); the GDPR (European Union General Data Protection Regulation); the UK Data Protection Act 2018; Law 1581 of 2012 and Decree 1377 of 2013 (Colombia); and any other applicable data protection regulations.

For more information, please review our Privacy Policy and Terms & Conditions at fuglytoenails.com.

I have read and agree to the Legal Consent Clause, including consent to collect and process my personal and health data for telemedicine evaluation and treatment purposes, and authorization to receive communications via email, phone calls, SMS text messages, WhatsApp, and other electronic messaging channels as described above. I understand this is not a condition of purchase and I may withdraw at any time.

I authorize Fugly Toenails™ and JAWS Podiatry to use and disclose my Protected Health Information (PHI) to licensed physicians involved in my evaluation and treatment, as required by HIPAA. I understand I have the right to revoke this authorization in writing at any time.

I agree to receive promotional information, health tips, and updates about Fugly Toenails™ products and services by email and/or SMS. You may unsubscribe at any time.

We respect your privacy. Your information is used solely to respond to your request and provide your treatment plan.

PRIVACY POLICY & PERSONAL DATA HANDLING POLICY