The image is a photograph of a medical form for pets. The form is titled "Pets are worth saving" and has a blue header with the text "Date of Arrival: 5/17/17". Below the header, there is a section titled "CACC" which is the date of arrival. 

The form has fields for the patient's name, address, phone number, fax number, and other relevant information. There is also a note that reads "Date" and "Description: Black/White". The form also has a space for the recipient's name and address.

At the bottom of the form, there are two fields - "FVRCP Sticker" and a "Rabies sticker". The first field is for the treatment and vaccination date, and the second field is labeled "FELVIV/IV Test". There are also fields for "Attitude", "Woods", "Strongid", "ml", "Praziquantel", and "Revolver".

Overall, the form appears to be a form for a pet's worth saving, as indicated by the text on the top right corner.