UROGEN RETURN/REPLACEMENT REQUEST FORM

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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:

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:

By checking this box, you authorize the submission of this form and certify that all information provided is true, accurate, and complete to the best of your knowledge.

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.

If you cannot complete this form with the information at your disposal, please contact the HUB at returns@UroGenSupport.com for assistance.

UROGEN RETURN/REPLACEMENT REQUEST FORM

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