USEF Medication Report Form

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USEF Medication Report Form

Competition Search

State

Month

Identification of Horse / Pony

Enter a Horse ID to autofill

Name

Age

Gender

Color

Weight

Entry #

Trainer

Owner

Breed / Discipline

Microchip

Prescribing Veterinarian and Administration Contact Information

Veterinarian

Veterinarian Email

Veterinarian Phone

Diagnosis

Flunixin administered?

Person Administering

Contact Email

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

Identification of Medication or Treatment

Medication
Treatment

Medication/Treatment Name

Amount

Strength

Administration Route

Administration Method

Location

Depth

Number of Shocks

Administration Date

Administration Time

No Medications Identified

Create