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 (Terbinafine) requires patients to be 18 years 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.Terbinafine is metabolized by the liver. This is a hard block for the oral Kit #1. If you answer Yes, you will be redirected to Kit #2 (topical only).
Yes
No
I'm not sure
4
Do you have chronic kidney disease or significantly reduced kidney function?* This field is required.
Yes
No
I'm not sure
5
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
6
Do you have an autoimmune condition or a weakened immune system?* This field is required.For example: lupus, psoriasis, HIV, or currently undergoing chemotherapy.
Yes
No
I'm not sure
7
Are you currently taking any medications that may interact with oral antifungal therapy?* This field is required.
Yes
No
I'm not sure
8
Which of the following are you currently taking? Select all that apply.These may interact with oral antifungal therapy (Terbinafine).
Warfarin or other blood thinners
Rifampin
Cyclosporine
Tricyclic antidepressants (e.g., amitriptyline)
Other antifungal medications
9
Are you currently pregnant, breastfeeding, or planning to become pregnant in the next 6 months?* This field is required.Terbinafine is contraindicated during pregnancy and breastfeeding — this is a hard block for Kit #1.
Yes
No
I'm not sure
10
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
11
How would you describe your nail condition right now?* This field is required.This determines your preliminary kit suggestion. The physician makes the final 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
12
Full Name* This field is required.
First Name
Last Name
13
Email Address* This field is required.
example@example.com
14
Phone Number
15
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
16
Legal Consent* This field is required.
I have read and agree to the Legal Consent Clause, including authorization to collect my health data for telemedicine evaluation and to receive communications via email, phone, SMS, WhatsApp, and other electronic channels. I may withdraw my consent at any time.
17
HIPAA Authorization* This field is required.
I authorize Fugly Toenails™ and JAWS Podiatry to use and disclose my Protected Health Information (PHI) to the physicians involved in my evaluation, as required by HIPAA. I may revoke this authorization in writing at any time.
18
Telemedicine Confirmation* This field is required.
I understand this is a telemedicine service. I confirm I am located in Florida at the time of this evaluation. Treatment eligibility is determined solely at physician discretion.
19
Optional Marketing Consent
I agree to receive promotional information and health tips from Fugly Toenails™ by email and/or SMS. I may unsubscribe at any time.
20
Hidden_dq_status
21
Hidden_dq_reason
22
Hidden_recommended_kit
23
Hidden_flag_liver
24
Hidden_flag_kidney
25
Hidden_flag_heart
26
Hidden_flag_immune
27
Hidden_flag_meds
28
Hidden_flag_preg
29
Hidden_flag_allergy
30
Hidden_service_area_status
31
Helper_yes
32
Helper_no
33
Helper_blocked
34
Helper_redirect_clear
35
Helper_redirect_kit2
36
Helper_under18
37
Helper_pregnancy_breastfeeding
38
Helper_antifungal_allergy
39
Helper_physician_review_required
40
Helper_eradication_kit
41
Helper_clear_nail_solution_kit
42
Helper_florida
43
Helper_outside_florida
44
Helper_liver_history
45
FINAL_ELEGIBILITY_RESULT
Should be Empty: