USPA MULTIPLE HORSE MEDICATION REPORT FORM

TOURNAMENT NAME*

HOST CLUB*

TEAM NAME*

Please scroll to the right to complete all of the required information.

	HORSE NAME:	COLOR:	SEX:	AGE:	PLAYER/ OWNER:	MEDICATION ADMINISTERED:	AMOUNT ADMIN:	ROUTE OF ADMIN:	DATE AND TIME:	REASON:

If this Medication Report is for emergency treatments within 24 hours of game as described in EMR Rule 4.4 please agree to the terms below and click box.

By checking this box, the examining veterinarian has verified that the treated condition is resolved, and the horse has been determined to be fit to play.

NAME OF VETERINARIAN* PRESCRIBING THE MEDICATION*

PHONE NUMBER OF PRESCRIBING VETERINARIAN*

SIGNATURE OF VETERINARIAN* PRESCRIBING THE MEDICATION*

DATE SIGNED*

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/PLAYER: Once this form is completed and submitted via the Jotform link on uspolo.org, it will automatically be emailed to equinewelfare@uspolo.org. The form must be RECEIVED PRIOR to the commencement of the USPA event in which the horse is playing. A copy of this form may be obtained, upon request, by the horse owner, the player, or the veterinarian who submitted the form. Requests can be submitted via email to equinewelfare@uspolo.org.

If you have any questions about the Equine Medications Rules please contact Beth Supik USPA Equine Welfare and Medications Program Representative. Cell: (443) 386- 6328 Email: BSupik@uspolo.org or equinewelfare@uspolo.org.