USEF Medication Report Form

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State

Month

Enter a Horse ID to autofill

Name

Age

Gender

Color

Weight

Entry #

Trainer

Owner

Breed / Discipline

Microchip

Veterinarian

Veterinarian Email

Veterinarian Phone

Diagnosis

Flunixin administered?

Person Administering

Contact Email

I would like to be considered for a Pergolide Therapeutic Use Exemption

Medication Name

Amount

Strength

Administration Route

Administration Method

Administration Date

Administration Time

No Medications Identified

Create