Full Name (required)
Date of Birth
Have you or a loved one used an E-Cigarette or “vaped”?
What brands of vape or E-Cigarette did you use?
Do you have proof of purchase such as credit or debit card transactions? Or receipts?
Have you or a loved one been to the hospital because of lung issues you believe are related to vaping?
Do you believe a loved one died from vaping?
Phone or Text Number