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