document.writeln('<iframe src=\"about:blank\" name=\"hidform25\" 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=\"myform25\" action=\"/plus/form/form.asp\" onSubmit=\"return(form_c(25));\"  target=\"hidform25\" ')
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=\"25\" 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=\"formstrck25\" 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=\"formstrck25\" 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\">常住地：</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=\"formstrck25\" id=\"常住地|%|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:200px\" id=\"KS_lianxiren\" name=\"KS_lianxiren\" ')
document.writeln('value=\"\">  </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=\"formstrck25\" 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:200px\" id=\"KS_weixin\" name=\"KS_weixin\" ')
document.writeln('value=\"\">  </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\">城市名称</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:100px\" id=\"KS_chengshi\" name=\"KS_chengshi\" ')
document.writeln('value=\"\"><span class=\"formstrck25\" id=\"城市名称|%|KS_chengshi|%|1\" style=\"display:none\"></span><font ')
document.writeln('color=\"red\"> * </font> <span style=\"margin-top:5px\">想到哪个城市语训?')
document.writeln('</span>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">机构名称</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:100px\" id=\"KS_jigoumingcheng\" ')
document.writeln('name=\"KS_jigoumingcheng\" value=\"\"> <span style=\"margin-top:5px\">想到哪家机构语训?')
document.writeln('</span>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">专家姓名</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:100px\" id=\"KS_zhuanjiaxingming\" ')
document.writeln('name=\"KS_zhuanjiaxingming\" value=\"\"> <span style=\"margin-top:5px\">想找哪位语训专家?</span>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">您的提问</td>')
document.writeln('  <td><textarea style=\"width:250px;height:100px\" rows=\"5\" id=\"KS_nindetiwen\" name=\"KS_nindetiwen\"></textarea>  ')
document.writeln('</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('')