document.writeln('<iframe src=\"about:blank\" name=\"hidform24\" style=\"width:0px;height:0px;display:none\"></iframe>')
document.writeln('<script src=\"/ks_inc/common.js\"></script>')
document.writeln('<script src=\"/ks_inc/form_ck.js\"></script>')
document.writeln('<form name=\"myform24\" action=\"/plus/form/form.asp\" onSubmit=\"return(form_c(24));\"  target=\"hidform24\" ')
document.writeln('method=\"post\"> ')
document.writeln('<table width=\"100%\" border=\"0\" cellspacing=\"2\" cellpadding=\"1\">')
document.writeln('<input type=\"hidden\" value=\"Save\" name=\"action\"/>')
document.writeln('<input type=\"hidden\" value=\"24\" name=\"id\"/>')
document.writeln('<input type=\"hidden\" value=\"0\" name=\"m\"/>')
document.writeln('<input type=\"hidden\" value=\"0\" name=\"d\"/>')
document.writeln('<input type=\"hidden\" value=\"{$ToUserName}\" id=\"tousername\" name=\"tousername\"/>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\"  width=\"90px\">患者姓名</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:100px\" id=\"KS_xingming\" name=\"KS_xingming\" ')
document.writeln('value=\"\"><span class=\"formstrck24\" id=\"患者姓名|%|KS_xingming|%|1\" style=\"display:none\"></span><font ')
document.writeln('color=\"red\"> * </font> <span style=\"margin-top:5px\">请填真名,勿写小名</span>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">性别：</td>')
document.writeln('  <td><input type=\"radio\" id=\"KS_xingbie\" name=\"KS_xingbie\" value=\"男\">男<input type=\"radio\" id=\"KS_xingbie\" ')
document.writeln('name=\"KS_xingbie\" value=\"女\">女  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">年龄：</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:200px\" id=\"KS_nianling\" name=\"KS_nianling\" ')
document.writeln('value=\"\"><span class=\"formstrck24\" id=\"年龄|%|KS_nianling|%|1\" style=\"display:none\"></span><font color=\"red\"> * ')
document.writeln('</font>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">常驻地：</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:200px\" id=\"KS_changzhudi\" ')
document.writeln('name=\"KS_changzhudi\" value=\"\"><span class=\"formstrck24\" id=\"常驻地|%|KS_changzhudi|%|1\" style=\"display:none\">')
document.writeln('</span><font color=\"red\"> * </font>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">联系人名</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:100px\" id=\"KS_lianxiren\" name=\"KS_lianxiren\" ')
document.writeln('value=\"\"> <span style=\"margin-top:5px\">也可是患者本人</span>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">联系手机</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:200px\" id=\"KS_shouji\" name=\"KS_shouji\" ')
document.writeln('value=\"\"><span class=\"formstrck24\" id=\"联系手机|%|KS_shouji|%|1\" style=\"display:none\"></span><font color=\"red\"> * ')
document.writeln('</font>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">微信号码：</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:100px\" id=\"KS_weixin\" name=\"KS_weixin\" ')
document.writeln('value=\"\"> <span style=\"margin-top:5px\">若有请填上</span>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">qq号码：</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:200px\" id=\"KS_qq\" name=\"KS_qq\" value=\"\">  ')
document.writeln('</td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">如何联系</td>')
document.writeln('  <td><input type=\"checkbox\" id=\"KS_ruhelianxi\" name=\"KS_ruhelianxi\" value=\"打电话\">打电话<input type=\"checkbox\" ')
document.writeln('id=\"KS_ruhelianxi\" name=\"KS_ruhelianxi\" value=\"发短信\">发短信<input type=\"checkbox\" id=\"KS_ruhelianxi\" ')
document.writeln('name=\"KS_ruhelianxi\" value=\"qq\">qq<input type=\"checkbox\" id=\"KS_ruhelianxi\" name=\"KS_ruhelianxi\" value=\"微信\">')
document.writeln('微信 <span style=\"margin-top:5px\"> 可多选</span>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">助听器店</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:100px\" id=\"KS_zhutingqidian\" ')
document.writeln('name=\"KS_zhutingqidian\" value=\"\"> <span style=\"margin-top:5px\">想去哪家助听器店?</span>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">语训机构</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:100px\" id=\"KS_yuxunjigou\" ')
document.writeln('name=\"KS_yuxunjigou\" value=\"\"> <span style=\"margin-top:5px\">想去哪家语训机构?</span>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">简要说明</td>')
document.writeln('  <td><textarea style=\"width:250px;height:100px\" rows=\"5\" id=\"KS_jianyaoshuoming\" name=\"KS_jianyaoshuoming\">')
document.writeln('</textarea>  </td>')
document.writeln('</tr>')
document.writeln('<tr><td colspan=\"2\" class=\"subtdbg\" align=\"center\"><input type=\"submit\" value=\"确认提交\" name=\"submit1\"></td>')
document.writeln('</tr>')
document.writeln('</table>')
document.writeln('</form>')
document.writeln('')