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):
(please check one below if injectable)
Date of Administration

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time of Last Administration
(please check one)
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
2 digit month, 2 digit day, 4 digit yearDate
Time of Administration
*ALL SIGNATURES ARE REQUIRED
Person Administering the Medication(s) Print Name
Signature
Phone Number
Format: (000) 000-0000.
Veterinarian Prescribing Medication(s) (If different than person administering, if same please denote.) Print Name
Signature
Phone Number
Format: (000) 000-0000.
Rider (Exhibitor) Verification (If different than person administering - if same please denote.) Print Name
Signature
Phone Number
Format: (000) 000-0000.
Owner Verification (If different than person administering - if same please denote.) Print Name
Signature
Phone Number
Format: (000) 000-0000.
Name of Show/Event
Date(s) Held

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email
example@example.com
Should be Empty:

MEDICATIONS REPORT FORM

A. IDENTIFICATION OF HORSE

B.IDENTIFICATION OF THERAPEUTIC MEDICATION

*ALL SIGNATURES ARE REQUIRED