Request Live Virtual Consultation

Eligibility & Location Confirmation

What is your state of residence?

Will you be physically located in the State of Florida at the time of your video appointment?

Are you 18 years of age or older?

Do you currently have any of the following symptoms? Severe pain, drainage, spreading redness, warmth, fever, or signs of an active infection.

If you are experiencing any of these symptoms, a live video consultation may not be appropriate. These symptoms may require in-person medical care or urgent medical attention.

Based on your answers, we are unable to proceed with a Live Virtual Consultation through Fugly Toenails™ at this time.

Fugly Toenails™ telemedicine services are available only to eligible adults who are Florida residents and physically located in the State of Florida at the time of the video appointment.

If you are experiencing severe pain, drainage, spreading redness, warmth, fever, or signs of an active infection, please seek in-person medical care or urgent medical attention from a licensed healthcare provider.

Patient Information & Consultation Request

Full Name

First NameLast Name

Email Address

example@example.com

Phone Number

What best describes your situation?

Questions or concerns you'd like to discuss during the consultation

Let us know what you'd like to focus on during your 30-minute video appointment.

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.

Preferred contact method for appointment coordination (Our team will use this method to coordinate your video appointment)

Which days of the week work best for your video consultation? (Select all that apply)

Which time slots work best for your video consultation? All times Eastern Time. Select all that apply.

How soon would you like to have the consultation?

Any additional scheduling preferences or notes?

For example: specific dates to avoid, best times to reach you, etc.

Identity Verification

Florida law requires us to verify your identity before any medical evaluation. The following documents are protected under HIPAA and used solely for verification purposes.

Government-Issued Photo ID

Please upload a clear photo or scan of a valid, unexpired government-issued photo ID. The full legal name and date of birth must be clearly readable. This document is protected under HIPAA and used solely to verify your identity.

Type of Identification Document

Florida Residency Documentation

Required only if your ID document does not show a Florida address. Acceptable documents (dated within the last 90 days): utility bill, bank statement, lease agreement, or government correspondence showing your name and a Florida address.

Full Legal Name (exactly as it appears on your ID)

Type your name exactly as printed on the identification document, including middle name if shown.

Date of Birth (exactly as it appears on your ID)

Hidden_identity_verification_status

Hidden_identity_verified_by

Hidden_identity_verification_date

Hidden_identity_rejection_reason

Hidden_residency_proof_required

Hidden_residency_proof_type

LEGAL CONSENT & AUTHORIZATION FOR PERSONAL DATA PROCESSING AND ELECTRONIC COMMUNICATIONS

By submitting this form, I voluntarily authorize Fugly Toenails™ and JAWS Podiatry to collect, store, use, and process my personal information, contact information, health-related information, intake responses, uploaded photos, and any other information I provide through this form for purposes related to eligibility review, appointment coordination, live telemedicine consultation, medical follow-up, treatment coordination, prescription fulfillment coordination if clinically appropriate and applicable, patient support, and communications related to podiatric telemedicine services for nail fungus (onychomycosis), athlete's foot (tinea pedis), and related foot or nail concerns.

I understand that Fugly Toenails™ telemedicine services are available only to eligible adults who are Florida residents and physically located in the State of Florida at the time of the video appointment. I also understand that submitting this form does not guarantee that I am eligible for telemedicine care, does not guarantee that I will receive a diagnosis, and does not guarantee that any prescription treatment will be issued.

I understand that any medical evaluation, diagnosis, treatment recommendation, prescription decision, or prescription fulfillment coordination is subject to review and approval by a Florida-licensed provider involved in my consultation and treatment. Prescription products, if clinically appropriate, may only be issued after provider review and are subject to medical eligibility, provider discretion, and applicable laws and regulations.

I understand that the Live Virtual Consultation fee is $300 USD and that payment will be processed at the time my appointment is confirmed by the Fugly Toenails™ team, prior to the video consultation. I have reviewed the Refund & Return Policy.

This authorization includes communications from Fugly Toenails™, JAWS Podiatry, and their authorized staff or representatives via email, phone calls, SMS text messages, WhatsApp, and other electronic or messaging communication channels, strictly for purposes related to my eligibility review, appointment coordination, video consultation, care coordination, treatment instructions, prescription status updates if applicable, follow-up, administrative support, and health-related information relevant to my case.

By providing my phone number and submitting this form, I expressly consent to receive transactional and informational communications related to my request and consultation, including but not limited to appointment coordination, appointment confirmation, requests for additional information, scheduling coordination, treatment instructions, prescription-related updates if applicable, follow-up reminders, and health-related information relevant to my case.

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 I may request assistance by replying HELP. I understand that opting out of SMS or messaging communications may affect how Fugly Toenails™ and JAWS Podiatry are able to communicate with me electronically, but I may request communication through another available channel.

I understand that health-related information shared through this form, through the live video consultation, or through electronic communications may include Protected Health Information (PHI), and that Fugly Toenails™ and JAWS Podiatry will implement reasonable safeguards to protect my information in accordance with applicable privacy and healthcare requirements, including HIPAA where applicable. The Live Virtual Consultation is conducted through a secure, HIPAA-compliant video platform.

I acknowledge that telemedicine services do not replace in-person medical care when clinically necessary. If I am experiencing severe pain, drainage, spreading redness, warmth, fever, signs of an active infection, or any urgent medical concern, I understand that I should seek in-person medical care or urgent medical attention from a licensed healthcare provider.

I understand that Fugly Toenails™ and JAWS Podiatry may decline to proceed with a live video consultation or may recommend in-person care if my answers, uploaded photos, symptoms, location, age, medical history, or other information indicate that telemedicine may not be appropriate for my situation.

This consent is granted in accordance with applicable privacy, healthcare, telehealth, and electronic communications laws and regulations, including, where applicable, HIPAA, the Florida Telehealth Act, the Telephone Consumer Protection Act (TCPA), the CAN-SPAM Act, and other applicable federal, state, and data protection requirements.

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

Authorization and Acceptance of Legal Consent

I have read and agree to the Legal Consent Clause, including authorization to collect, use, and process my personal and health-related information for eligibility review, appointment coordination, live telemedicine consultation, treatment coordination, follow-up, prescription-related coordination if clinically appropriate and applicable, and related electronic communications as described above. I understand that submitting this form does not guarantee eligibility, diagnosis, prescription treatment, or prescription fulfillment.

HIPAA Authorization (Required)

I authorize Fugly Toenails™ and JAWS Podiatry to use and disclose my Protected Health Information (PHI) to Florida-licensed providers, authorized clinical staff, and authorized support personnel involved in my eligibility review, appointment coordination, live telemedicine consultation, treatment coordination, prescription-related coordination if clinically appropriate and applicable, follow-up, and patient support, as permitted by HIPAA and applicable law. This authorization remains valid until the completion of my eligibility review, live telemedicine consultation, treatment coordination, prescription-related coordination if applicable, and related follow-up, unless I revoke it earlier in writing. I understand that I have the right to revoke this authorization in writing at any time.

Marketing communications (Optional)

I agree to receive optional promotional information, health tips, educational content, product updates, and special offers from Fugly Toenails™ and JAWS Podiatry by email and/or SMS. I understand that this consent is optional, is not required to receive a telemedicine evaluation or treatment, and may be withdrawn at any time by using the unsubscribe link in any email or by replying STOP to any SMS message.

We respect your privacy. Your information is used solely to respond to your request, coordinate your virtual evaluation, and provide appropriate next steps based on provider review.

PRIVACY POLICY & PERSONAL DATA HANDLING POLICY

Request Live Virtual Consultation — Fugly Toenails™

Appointment Coordination