Medical Report Form

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Medical form to be submitted to ESC within an hour of administering therapuetic medications to horses competing at an ESC event. As well as to horses at an ESC event exhibiting an elevated temperature, especially if greater than 101 degrees.

Name of Horse Show *

Entry Number *

Breed of Horse *

Sex *

Stallion

Mare

Gelding

Registered Name of Horse *

Date Foaled * +

Weight *

Color *

Body Temperture

Trainers Full Name *

Owners Full Name *

Medication Identification

Name of Medication *

Amount Given *

Strength Given *

How Administered *

Date Given * +

Time Given *

This was an emergency use of Flunixin (Banamine) *

Yes

No

Is there any risk of a viral or bacterial contagious infection that would warrant biosecurity protocols? *

No Risk

No Risk, Mild Fever <95

Possible Risk, Higher Fever >/=101

High Risk, Recommend Biosecurity Protocols

Diagnosis and therapeutic reason for giving *

Did the agent or its representative administer the medication? *

Administered by Agent/Representatives

Administered by Vet

Signature Required of Person Administering *

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Agent Responsible

First Name *

Last Name *

Farm Name *

Cell Phone Number *

Agent's Email Address *

Veterinarian

First Name *

Last Name *

Cell Phone Number *

State Licensed *

Vet Email Address *

Retype Email *

Name of Practice *