UROGEN RETURN/REPLACEMENT REQUEST FORM

Initiate a request for replacement or credit to your account by completing all information below. All claims for replacement and credit are subject to the applicable terms of UroGen's Return Goods Policy.

Choose product:

Zusduri

Jelmyto

Distributor PO# / Order ID# :

Order Date :

Lot #:

Expiration Date:

Number of doses returned:

Does your Site of Care prepare the product on site, or do you use a UroGen authorized pharmacy as part of the product preparation program?

Self-preparation – Product is prepared on site by the Site of Care

UroGen-authorized pharmacy – Product is prepared by a UroGen-authorized pharmacy

Reason treatment did not occur:

Is your office requesting a replacement?

Replacement

Credit Request

Contact information:

Site-of-Care Name:

Street Address Line 1:

Street Address Line 2 (optional):

City:

State:

ZIP Code:

Email:

Phone #:

Signature:

Name of person completing the form:

Role in Organization:

Please read UroGen’s Return Goods Policy carefully prior to completing and submitting this form.

NOTE: Allow at least 30 business days for review of your credit request and to receive your credit memo from the distributor via email. For questions regarding the status of your credit request, please contact Cardinal Health at 877-488-3569 or Cencora-Besse Specialty Distributor at 800-543-2111.