Medical declaration form for an ioc restricted substance

STRICTLY CONFIDENTIAL
Fédération Equestre Internationale – Av. de Rumine 37 – CH - 1005 LAUSANNE Tel : +41 21 310 47 47/Fax : +41 21 310 47 60 DECLARATION OF USE
Please complete all sections in capital letters or typing
This Declaration of Use (DoU) concerns the following routes of administration of:
 glucocorticosteroids:
- intra-articular/periarticular/peritendinous/epidural/intradermal injections Topical preparations when used for dermatological, including iontophoresis/phonophoresis, auricular, nasal, ophthalmic, buccal, gingival and perianal disorders are not prohibited and do not require any form of Declaration of Use.  Beta-2 agonists
- inhaled salbutamol and salmeterol
It should be noted that supratherapeutic dosages may result in a urinary level of >1000ng/mL which could result in an adverse analytical finding (AAF). 1. Athlete Information

Surname: .
Female  Male  Date of Birth (d/m/y): ……………………………………… City: ………………………. Country: ………………………………. Postcode: …………. . Tel.:………………………………………. E-mail: …………………………………………………………………. International or National Sport Organization: …………………………………………………………………………… If athlete with disability, indicate disability: . STRICTLY CONFIDENTIAL
2. Medical Information
Diagnosis:
.….…….………………………………………………………………………………………………………………………………………………… Medical information (detailed description of symptoms, different treatments administered)
…………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………. …………………………………………………………………………………………………………………………………………………………. …………………………………………………………………………………………………………………………………………………………… 3. Medication details
Frequency Intended duration of
Prohibited substance(s):
Treatment e.g.
Generic name(s)
4. Medical practitioner’s declaration
I certify that the above-mentioned treatment is medically appropriate and that the use of
alternative medication not on the prohibited list would be unsatisfactory for this condition.
Name:…………………………………………………….
Medical speciality: …………………………………………………………………………………………………………………………….
Address: ……………………………………………………………………………………………………………………………………………….
Tel.: ……………………………………………………………………. Fax: ……………………………………………………………
E-mail: ……………………………………………………………………………………………………………………………………………………
Signature of Medical Practitioner: . Date: ………………………………….
6. Athlete’s declaration

I, ………………………………………………………………………………. certify that the information under 1. is accurate
and that I am requesting approval to use a glucocorticosteroids. I authorize the release of personal
medical information to the FEI as well as to WADA staff, to the WADA TUEC (Therapeutic Use
Exemption Committee) and to other Anti-Doping Organizations (ADOs) under the provisions of the
Code. I understand that if I ever wish to revoke the right of these organizations to obtain my health
information on my behalf, I must notify my medical practitioner and the FEI in writing of that fact.
Athlete’s signature: .
STRICTLY CONFIDENTIAL

Parent’s/Guardian’s signature: .
(if the athlete is a minor or has a disability preventing him/her to sign this form, a parent or guardian shall sign together with or on behalf of the athlete) Incomplete DoU will be returned and will need to be resubmitted.
IMPORTANT
You must declare the use of this medication on the Doping Control Form every time you are tested.
Please submit the completed form to the FEI a or
by fax to: +41 21 310 47 60 and keep a copy for your records.

Source: http://www.endurancegb.co.uk/ItemFiles/FEI%20-%20Declaration%20of%20Use%20Form%202010.pdf