MEDICATIONS REPORT FORM

MEDICATIONS REPORT FORM
Important Reminders:

Please review this form carefully and sign that all information is correct.

Form completion and submission does NOT guarantee compliance.

Form is not required for Permitted substances. Please check the medications database for classification.
A. IDENTIFICATION OF HORSE
NRHA Licensed Name of Horse*
Competition License Number
Age*
Sex*
Color*
Breed
Weight*
Responsible Party Name (Exhibitor) *
Exhibitor Membership ID #*
Owner's Name*
B.IDENTIFICATION OF THERAPEUTIC MEDICATION
Product Name*
Amount Administered*
Strength
Route of Administration (please check one):*

OralTopicalInhalationInjectable
(please check one below if injectable)

IntramuscularIntra-articularIntravenousSubcutaneous
Date of Administration*

MonthDayYear
Date
Time of Last Administration
(please check one)

ampm
Diagnosis and Reason for Administering (This must be for a therapeutic purpose defined by diagnosis or treatment of an existing illness or injury and must be descriptive)
Shipping, clipping, training, turning out, routine floating or cleaning of teeth, mane pulling, non-emergency shoeing, non-diagnostic nerve blocking, uncasting, etc. are examples of unacceptable reasons for administration.
Amount Administered
Date of Administration*

MonthDayYear
Date
Time of Administration
*ALL SIGNATURES ARE REQUIRED
Person Administering the Medication(s) Print Name*
Signature*

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Phone Number*
Veterinarian Prescribing Medication(s) (If different than person administering, if same please denote.) Print Name*
Signature*

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Phone Number*
Rider (Exhibitor) Verification (If different than person administering - if same please denote.) Print Name*
Signature*

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Phone Number*
Owner Verification (If different than person administering - if same please denote.) Print Name*
Signature*

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Phone Number*
Name of Show/Event*
Date(s) Held*

MonthDayYear
Date
Email*
example@example.com
Should be Empty:

MEDICATIONS REPORT FORM

A. IDENTIFICATION OF HORSE

B.IDENTIFICATION OF THERAPEUTIC MEDICATION

*ALL SIGNATURES ARE REQUIRED