MEDICATIONS REPORT FORM

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

You DO NOT have to use this form if you are administering: Diclofenac (Surpass®), Phenylbutazone (Bute®), Flunixin Meglumine (Banamine®), Ketoprofen (Ketofen®), Firocoxib (Equioxx®), Omeprazole (Gastroguard®), Methocarbamol (Robaxin®), Furosemide (Salix®), Altrenogest (Regumate®), Isoxsuprine Hydrochloride (Vasodilan®), or Dexamethasone (Dexjet SP®). These must be administered within the limits outlined in the NRHA Handbook.
A. IDENTIFICATION OF HORSE
Registered/Licensed Name of Horse*
Age*
Sex*
Color*
Breed
Weight*
Entry Number*
Trainer's Name*
Owner's Name*
B.IDENTIFICATION OF THERAPEUTIC MEDICATION

(MUST BE COMPLETED IF SECTION 8 APPLIES)
*If medication is being administered by anyone other than the prescribing veterinarian, please include a picture of the Rx.
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):
C. ROMIFIDINE DECLARATION

(ONLY COMPLETE IF ADMINISTERING ROMIFIDINE (SEDIVET®) (*ALL SIGNATURES ARE REQUIRED, if any are missing, no matter the circumstances, it will be considered a medications violation)
Amount Administered
Date of Administration

MonthDayYear
Date
Time of Administration
(please check one)

ampm
Route of Administration (Please check one)

IntravenousIntramuscular
*ALL SIGNATURES ARE REQUIRED FOR THE IDENTIFICATION OF THERAPEUTIC MEDICATION AND/OR ROMIFIDINE DECLARATION
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

C. ROMIFIDINE DECLARATION

*ALL SIGNATURES ARE REQUIRED FOR THE IDENTIFICATION OF THERAPEUTIC MEDICATION AND/OR ROMIFIDINE DECLARATION