The image is a medical form with two footprints on it. The form is titled "Certificate of Discharge" and has a barcode on the top right corner. 

On the left side of the form, there is a black and white image of a baby's footprints. The footprints are identical and appear to be imprinted on a white background. On the right side, there are two smaller images of the same footprints, one on top of the other. The first image is of the baby's left foot and the second is of a right foot.

At the top left corner of the page, there has a label that reads "Hospital No. 1058" and a bar code. Below the label, there appears to be a section for the patient's name, address, and other medical information. The bottom right corner has a signature and a note that says "I certify that during the discharge procedure I checked the patient and I have received my baby."

Overall, the form is likely used to certify a child's discharge from a hospital or medical facility.