Off-Licence Consent Form

Please use this form to consent to the use of off-licence drugs.

First Name

Last Name

Horse's Name

Horse Species

Horse Passport Number

Horse Microchip Number

Food Processing Status

Status of this Medicine

Disease/diagnosis (if known)

Food chain status of Medicine

I declare that the info I’ve provided is accurate & complete

STEPS OF THE PRESCRIBING CASCADE CONSIDERED BEFORE USING THIS MEDICINE

Additional notes

The medicine is being used under the prescribing cascade and outside the relevant marketing authorization (where relevant).
This means that the medicine has not passed the regulatory assessments for safety, quality and/or efficiency for the use proposed.
The use of this medicine at the given dose in this species is well recognised and represents standard clinical practice.
I have been made aware of, and accept that there may be adverse effects associated with the use of this medicine in this animal
I have been provided with written details of this medicine in the form of a client information leaflet* (either hard copy or by email) and will read this information and raise any additional questions with the veterinary surgeon before administering any further doses of this medicine.

I am the owner/responsible keeper of the horse described above. I confirm that the above details have been explained to me.

I confirm that I am over 18 years of age and consent to the use of this medicine in this horse.

Your Signature

Select a date

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