Veterinarian Forms Bleeder Certification-Salix Declaration Name of Horse* Tattoo* Year Foaled* Color* Sex*MF Select as applicable below, provide required information and submit as required to the Tampa Bay Downs Salix Coordinator. Bleeder's Certificate: *This is to certify that the horse identified above exhibited Exercise Induced Pulmonary Hemorrhage (EIPH) at the following track or farm and date of EIPH: Location of Track or Farm Date EIPH Occurred and it is requested that the horse be placed on the Tampa Bay Downs Salix List. The horse identified above was seen bleeding from the nostril(s): after a race or, after a workout An endoscopic examination was not necessary to diagnose EIPH An endoscopic examination was performed to confirm the diagnosis of EIPH. Doctor's Name Doctor's name the endoscopic examination was performed by. When utilized as a Bleeder’s Certificate, this completed form must be submitted to the Tampa Bay Downs Salix Coordinator within 10 days of the EIPH incident. Declaration To: Administer Furosemide (Salix) The trainer of record and attending veterinarian for the horse identified above attest that it has been determined that it is in the best interest of the horse to place it on the Tampa Bay Downs Salix List in the absence of signs of EIPH, and to race the horse with Salix administered by a licensed veterinarian, contracted by Tampa Bay Downs, no later than four (4) hours prior to post time of the race in which the horse is entered. The trainer of record understands that the administration of Salix may NOT be discontinued without first: Providing written verification from the attending veterinarian that it is in the best interest of the horse listed above to discontinue the use of Salix and Completing and submitting the required Tampa Bay Downs form, Request to Discontinue Salix, to the Tampa Bay Downs Salix coordinator no later than 48 hours prior to racing the horse listed above without Salix. This notification must be submitted to the Tampa Bay Downs Salix Coordinator prior to entry of the horse listed above in a scheduled pari-mutuel race. This notification must be submitted to the Tampa Bay Downs Salix Coordinator prior to entry of the horse listed above in a scheduled pari-mutuel race. Discontinue Furosemide (Salix) Administration The trainer of record and attending veterinarian for the horse identified above attest that it has been determined that it is in the best interest of the horse to remove it from the Tampa Bay Downs Salix List. The horse must remain off Salix for at least sixty (60) days unless it exhibits signs of EIPH. The completed form must be submitted to the Tampa Bay Downs Salix Coordinator no later than 48 hours prior to the scheduled post time of the race the horse is entered to run when utilized as a Declaration to Administer Salix, or as a Declaration to Discontinue Salix as applicable. Today's Date Veterinarian Name * Signature of Veterinarian* Trainer of Record Name* Signature of Trainer of Record Vets Office: 813-855-4401, ext. 1355 Racing Office Fax: 813-298-1560