USPA MULTIPLE HORSE MEDICATION REPORT FORM

TEAM NAME:

NAME OF VETERINARIAN* PRESCRIBINGTHE MEDICATION*
PHONE NUMBER OF PRESCRIBING VETERINARIAN*
SIGNATURE OF VETERINARIAN* PRESCRIBINGTHE MEDICATION*

Clear
DATE SIGNED*

MonthDayYear
Date
Hour MinutesAM/PM Option
*NOTE: PRESCRIBING VETERINARIAN MUST BE LICENSED IN THE STATE WHERE THE EVENT IS TAKING PLACE

C. INSTRUCTIONS TO HORSE OWNER/RIDER: This form must be emailed of faxed to the USPA. The form must be RECEIVED PRIOR to the commencement of the USPA event in which the horse is competing. Please retain a file copy of this form and request that your veterinarian retain a file copy. EMAIL: equinewelfare@uspolo.org FAX: (888) 391-7410

Please Call (800) 232- 8772 if you have any questions about the Equine Drugs and Medications Rules
Should be Empty: