New Customer Worksheet

^* Required fields

CUSTOMER

New Ship-ToNew Bill-To

Customer #

Credit Limit

^* DEA #

Terms

Class of Trade

Price Group

^* State License #

Sales Director

^* State License Exp Date

BILL-TO ADDRESS

^* Name of Customer

^* Address Line 1

Address Line 2

^* City

^* State

^* Zip code

^* Contact Person

^* Phone

BILL-TO ACCT

SHIP-TO ADDRESS

^* Name of Customer

SAM Territory ID

^* Address Line 1

MSL Territory ID

Address Line 2

^* City

^* State

^* Zip code

SHIP-TO ACCT

^* Phone

CONTACTS: (Needed if Photocure or DDN needs to contact the Customer about the order, billing or shipping)

^* Order Processing Contact

^* Phone

^* Accounting Contact

^* Phone

^* Receiving Contact

^* Phone

^* Form Completed By

^* Date

Important Safety Information About Cysview^® (hexaminolevulinate HCl)

Cysview is not a replacement for random bladder biopsies or other procedures used in the detection of bladder cancer.

Anaphylactoid shock, hypersensitivity reactions, bladder pain, cystitis, and abnormal urinalysis have been reported after administration of Cysview. The most common adverse reactions seen in clinical trials were bladder spasm, dysuria, hematuria, and bladder pain.

Patient Care