If you are human, leave this field blank.
Are you a member of the public or a healthcare professional?
If you are a Healthcare Professional, please select below
Hospital Healthcare Professional
Other Healthcare Professional
Whose side effect?
At least one of the fields Patient initials, Patient gender, or Patient age at time of the side effect must be completed for a report to be successfully submitted. Please complete as many fields as possible.
Who experience the suspected side effect?
Patient Age at time of side effect
Patient Weight (kg)
Patient Height (m)
Any other white background
White and Black Carribbean
White and Black African
White and Asian
Any other mixed background
Any other Asian background
Any other black background
Any other ethnic group
About the e-cigarette
Name of Product
Brand of e-Liquid
Product Use Start Date
Product Use Finish Date
Strength in Nicotine (mg)
Model or Batch Number
Action taken with this e-cigarette as a result of the reaction
Where did you obtain the e-cigarette?
Bought in Pharmacy
Bought in another shop
Medicine taken by mother during pregnancy
Please enter details of the side effects experienced. A description of the side effects can be entered in the free-text box at the bottom of the page and more than one side effect can be entered if needed, simply click 'Add another Side Effect'.
Symptom Start Date
Symptom End Date
Please select an outcome for the side effect
Recovered with some lasting effects
Side Effect Continuing
If the appropriate term for the side effect cannot be found in the dictionary, you can describe in your own words in the bow provided (including the sequence of events, any treatment received, or any other relevant information)
Please describe how the side effects affected you by selecting from the options below (select all that apply)
Please use the below sections to tell us about any medicines you are taking, and any underlying medical conditions or allergies
Are any medicines being taken, or have been taken in the last 3 months (including prescription, over the counter or herbal medicines)?
Other information you think might be important, including any other medical condition, any allergies that the person may have, results of any tests performed etc.
Was a doctor, pharmacist or other healthcare professional told about the suspected side effect?
Did your doctor, pharmacist or other healthcare professional complete a Yellow Card on your behalf?
Are you happy for the MHRA to contact you in the future to discuss the suspected side effect or ask for additional information that might help us better understand the case?
Would you like a copy of this report to be sent to your GP surgery/practice or any other healthcare professional?
If we need further information to help us understand the case (e.g. medical information, test results) do we have your permission to contact your doctor directly for it? If we need further information to help us understand the case (e.g. medical information, test results) do we have your permission to contact your doctor directly for it?