Adverse Effects Form

Any personal information disclosed within this form is strictly confidential and safeguarded via data protection acts 1998 and 2000, it is important to fill out the fields accurately and honestly.

The contents of the form are transferred directly to the Medicines and Healthcare Products Regulatory Agency (MHRA). Health and safety of consumers is paramount. The yellow card scheme form below allows vital information of potential side effects and products to be declared and monitored by the MHRA.

Further information about the MHRA or the Yellow Card scheme can be accessed by clicking this link

Vape Dinner Lady Form

Are you a member of the public or a healthcare professional?

Reporter Details

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.

About the e-cigarette

Side Effects

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'.

Additional Details

Please use the below sections to tell us about any medicines you are taking, and any underlying medical conditions or allergies