Xodus Medical Custom Order Form (Page 2 of 2) in pdf

Xodus Medical Custom Order Form Page 2

Large Labels 10/ sheet

Xodus Medical Custom Order Form

Fax: 724-337-0555

For multiple sheets Xerox this form.

Please fill out this custom label sheet and fax to Xodus Medical, Inc. at 724-337-0555

Label Customizing: Large Labels 10/sheet

Marker requested? □ No □Yes- Type:________________ Include Ruler? □ Yes □No

Clear Labels?

□ No □Yes

1. Print the medication name on the lines below exactly how you want it to appear on the label.

Maximum of 25 characters

2. Select the color of the background and text from the choices below and write them on the

appropriate lines.

Background color choices: Red, orange, yellow, green, blue, purple, pink, black, white

and brown (Background color is not an option with Clear Labels)

Text color choices: Red, yellow, green, blue, purple, black, white and pink

3. Write the quantity of each label required on the quantity line

Medication

Background Color

Text Color

Quantity

Please fax to Xodus Medical at 724-337-0555

Rev. 4; 4/19/07

F060-2 Large Label Order Form

Xodus Medical Custom Order Form Page 2