Assessment Questionnaire – Toenail fungus treatment

First, let's find out if you have ANY of the symptoms of toenail fungus (tell us all you have): *

Thickened, brittle, crumbling nail(s)The fungus starts at distal tip and spreads laterallyThere are white, yellow, or brown debris on underside of nailsThe toenail has yellow/white or orange/brown colored streaksThere is some pain or discomfortThe more symptoms you have the more definite is the diagnosis

Good Job. Stage one is done!

You can now continue to the next stage.

Now lets make sure that there are no "red flags" that may prevent you from using Jublia

I have more than 3 toenail affected by the fungusI have more than 50% of individual nail involvementThe fungal infection spread to my white crescent (Lunula) on my toenailI notice lifting of the nail plate from the nail bedNone of the above apply

Houston, we may have a problem

It looks like your case is a bit more complex than our pharmacist can handle on their own.

If you have a prescription from your doctor we may still dispense it to you.

Please take a picture of your script and upload it here. We will contact you shortly.

Upload your prescription photo

No file chosen

YOU ARE ALMOST THERE

If NONE of the above “red flag” signs apply – you can now tell us more about the history of your toenail fungus

What treatments did you try so far and what was the result?

Last, here is why Jublia may not be the right choice for you:

I am under 18I was never diagnosed by a doctor with toenail fungusI am Immunocompromised due to a drug I am taking or disease state (like: HIV, cancer etc.)I have diabetes or peripheral circulatory disordersI have a disease that causes nail deformityI have history of trauma to the nail(s)I have pitting of the nail(s)I am using a medication that can cause nail disorderNone of the above apply

Houston, we may have a problem

It looks like your case is a bit more complex than our pharmacist can handle on their own.

If you have a prescription from your doctor we may still dispense it to you.

Please take a picture of your script and upload it here. We will contact you shortly.

Upload your prescription photo

No file chosen

OKAY, NOW WHAT?

If you have NOT checked ANY of the above boxes then there is a strong chance that you HAVE a toenail fungus and Jublia may help you treat it.

For your reassurance, you could ask your doctor to perform a “KoH test” to confirm this diagnosis.

You are now welcome to leave your contact information and our pharmacist will call you to go over your answers before we ship you your Jublia.

Your first and last name *

M/F *

Date of birth *

Month

Day

Year

Email Address *

Phone *

Street AddressShipping address

Apartment, suite, etc

City

State

ZIP code

Please upload two photos to verify your identity

Please take a photo of your photo ID and a selfie photo of your face to compare

Are there any drug allergies to note?

I have no known drug allergies

List what other medications you are currently taking?

I am currently not taking any medications

Any final notes you would like to leave to our pharmacist?