Fugly Toenails | Eligibility Screener

1
Do you have one or more toenails that appear discolored, thickened, brittle, or detached from the nail bed?* This field is required.
Yes
No
I'm not sure
2
How old are you?* This field is required.Oral antifungal treatment with terbinafine is considered only for eligible adults age 18 or older.
Under 18 years old
18 – 29 years old
30 – 49 years old
50 – 64 years old
65 years or older
3
Do you have a history of liver disease, hepatitis, or elevated liver enzymes?* This field is required.Certain liver conditions may affect whether oral antifungal treatment is appropriate. Your response helps us determine the safest preliminary treatment pathway for provider review.
Yes
No
I'm not sure
4
Have you been diagnosed with chronic or active liver disease?* This field is required.Examples include cirrhosis or active hepatitis. If you're not sure whether a past liver condition is currently active or chronic, select “I'm not sure.”
Yes
No
I'm not sure
5
Do you have chronic kidney disease or significantly reduced kidney function?* This field is required.
Yes
No
I'm not sure
6
Do you have a history of heart problems, including congestive heart failure or irregular heartbeat (arrhythmia)?* This field is required.
Yes
No
I'm not sure
7
Do you have an autoimmune condition or a weakened immune system?* This field is required.Examples include lupus, psoriasis, HIV, or currently undergoing chemotherapy.
Yes
No
I'm not sure
8
Are you currently taking any medications that may interact with oral antifungal therapy?* This field is required.
Yes
No
I'm not sure
9
Which of the following are you currently taking? Select all that apply.These medications may interact with oral antifungal therapy with terbinafine.
Warfarin or other blood thinners
Rifampin
Cyclosporine
Tricyclic antidepressants (e.g., amitriptyline)
Other antifungal medications
10
Are you currently pregnant, breastfeeding, or planning to become pregnant in the next 6 months?* This field is required.Pregnancy or breastfeeding may affect eligibility for oral antifungal treatment. Your response will be considered when determining the appropriate treatment pathway.
Yes
No
I'm not sure
11
Have you ever had an allergic reaction to Terbinafine, Fluconazole, or any other antifungal medication?* This field is required.
Yes
No
I'm not sure
12
How would you describe your nail condition right now?* This field is required.Your answer helps identify a preliminary treatment pathway. A licensed provider makes the final clinical determination.
Mild — slight discoloration, early changes, 1 nail
Moderate — thickening or discoloration on 1–3 nails
Severe — multiple nails, significant changes or detachment
Primarily athlete's foot (skin), minimal nail involvement
Not sure — I want the physician to evaluate
13
Full Name* This field is required.
First Name
Last Name
14
Email Address* This field is required.
example@example.com
15
Phone Number
16
State of residence — telemedicine available in Florida only* This field is required.
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
17
Legal Consent* This field is required.
I have read and agree to the Legal Consent Clause, including authorization for Fugly Toenails™ and JAWS Podiatry to collect, use, store, and process my personal information, contact information, screener responses, health-related information, and any information I voluntarily provide for purposes related to eligibility screening, telemedicine availability review, provider review if applicable, care coordination if I proceed, follow-up, and related electronic communications. I understand that submitting this eligibility screener does not create a doctor-patient relationship, does not constitute a medical diagnosis, does not guarantee eligibility for telemedicine care, and does not guarantee prescription treatment or prescription fulfillment.
18
HIPAA Authorization* This field is 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 eligibility screening, telemedicine availability review, provider review if applicable, care coordination, follow-up, and patient support, as permitted by HIPAA and applicable law. This authorization remains valid until the completion of my eligibility screening, related review, care coordination if applicable, and 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.
19
Telemedicine Confirmation* This field is required.
I understand this is an eligibility screener for a Florida-based telemedicine service. I confirm that I am a Florida resident and that I will be physically located in the State of Florida at the time of any virtual evaluation.I understand that screener results are preliminary and do not guarantee medical eligibility, diagnosis, prescription treatment, or prescription fulfillment. Any medical evaluation, treatment recommendation, prescription decision, or prescription-related coordination is subject to review and approval by a Florida-licensed provider based on medical eligibility, clinical appropriateness, provider discretion, and applicable laws and regulations.
20
Optional Marketing Consent
I agree to receive optional promotional emails and/or text messages from Fugly Toenails™ and JAWS Podiatry, including health education, service updates, product information, and special offers. I understand that this consent is optional and is not a condition of submitting this eligibility screener, receiving care, or purchasing any product or service. I may withdraw my consent at any time by using the unsubscribe link in any marketing email or by replying STOP to any marketing text message. Message and data rates may apply. Message frequency may vary.
21
Hidden_preliminary_fungipack
22
Hidden_screening_status
23
Hidden_oral_path_status
24
Hidden_lft_requirement
25
Hidden_provider_review_status
26
Hidden_liver_status
27
Hidden_liver_reason
28
Hidden_kidney_status
29
Hidden_kidney_reason
30
Hidden_heart_status
31
Hidden_heart_reason
32
Hidden_immune_status
33
Hidden_immune_reason
34
Hidden_meds_status
35
Hidden_meds_reason
36
Hidden_screening_fungipack
37
Helper_fugly_complete
38
Helper_fugly_topical
39
Helper_fugly_nail_skin
40
Helper_eligible_for_provider_review
41
Helper_provider_review_required
42
Helper_not_eligible_age
43
Helper_eligible_service_area
44
Helper_outside_service_area
45
Helper_oral_possible_candidate
46
Helper_oral_not_candidate
47
Helper_lft_baseline_required
48
Helper_status_pass
49
Helper_status_not_eligible
50
Helper_reason_none
51
Helper_liver_reason_no_history
52
Helper_liver_reason_chronic_active
53
Helper_liver_reason_prior_history
54
Helper_liver_reason_uncertain_history
55
Helper_liver_reason_uncertain_active
56
Helper_kidney_reason_no_history
57
Helper_kidney_reason_reported
58
Helper_kidney_reason_uncertain
59
Helper_heart_reason_no_history
60
Helper_heart_reason_reported
61
Helper_heart_reason_uncertain
62
Helper_immune_reason_no_history
63
Helper_immune_reason_reported
64
Helper_immune_reason_uncertain
65
Helper_meds_reason_no_interaction
66
Helper_meds_reason_reported
67
Helper_meds_reason_uncertain
68
Helper_lft_not_applicable
69
Hidden_dq_status
70
Hidden_dq_reason
71
Hidden_recommended_kit
72
Hidden_flag_liver
73
Hidden_flag_kidney
74
Hidden_flag_heart
75
Hidden_flag_immune
76
Hidden_flag_meds
77
Hidden_flag_preg
78
Hidden_flag_allergy
79
Hidden_service_area_status
80
Helper_yes
81
Helper_no
82
Helper_blocked
83
Helper_redirect_clear
84
Helper_redirect_kit2
85
Helper_under18
86
Helper_pregnancy_breastfeeding
87
Helper_antifungal_allergy
88
Helper_physician_review_required
89
Helper_eradication_kit
90
Helper_clear_nail_solution_kit
91
Helper_florida
92
Helper_outside_florida
93
Helper_liver_history
94
FINAL_ELEGIBILITY_RESULT
Should be Empty: