document.writeln('<iframe src=\"about:blank\" name=\"hidform2\" 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=\"myform2\" action=\"/plus/form/form.asp\" onSubmit=\"return(form_c(2));\"  target=\"hidform2\" 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=\"2\" 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\">患者全名</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=\"formstrck2\" id=\"患者全名|%|KS_xingming|%|1\" style=\"display:none\"></span><font color=\"red\"> * ')
document.writeln('</font> <span style=\"margin-top:5px\">请写全名</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:100px\" id=\"KS_nianling\" name=\"KS_nianling\" value=\"\">')
document.writeln('<span class=\"formstrck2\" id=\"年龄|%|KS_nianling|%|1\" style=\"display:none\"></span><font color=\"red\"> * </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:100px\" id=\"KS_suozaidi\" name=\"KS_suozaidi\" ')
document.writeln('value=\"\"><span class=\"formstrck2\" id=\"常驻地|%|KS_suozaidi|%|1\" style=\"display:none\"></span><font color=\"red\"> * </font> ')
document.writeln('<span style=\"margin-top:5px\">填省份和城市即可</span>  </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\">    患者家长或亲友姓名</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:100px\" id=\"KS_shouji\" name=\"KS_shouji\" value=\"\">')
document.writeln('<span class=\"formstrck2\" id=\"联系手机|%|KS_shouji|%|1\" style=\"display:none\"></span><font color=\"red\"> * </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_weixinhaoma\" name=\"KS_weixinhaoma\" ')
document.writeln('value=\"\"> <font color=\"red\"> * </font>  <span style=\"margin-top:5px\"> 若无微信请填 “0”</span></td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">人工耳蜗</td>')
document.writeln('  <td><input type=\"checkbox\" id=\"KS_rengonerwo\" name=\"KS_rengonerwo\" value=\"想了解国产耳蜗\"> 想了解国产耳蜗')
document.writeln('<input type=\"checkbox\" id=\"KS_rengonerwo\" name=\"KS_rengonerwo\" value=\"想了解进口耳蜗\"> 想了解进口耳蜗<input ')
document.writeln('type=\"checkbox\" id=\"KS_rengonerwo\" name=\"KS_rengonerwo\" value=\"想了解国际最新耳蜗\"> 想了解国际最新耳蜗<span ')
document.writeln('class=\"formstrck2\" id=\"人工耳蜗|%|KS_rengonerwo|%|7\" style=\"display:none\"></span><font color=\"red\"> * </font> <span ')
document.writeln('style=\"margin-top:5px\">可多选</span>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">病情简述</td>')
document.writeln('  <td><textarea style=\"width:250px;height:100px\" rows=\"5\" id=\"KS_jianshu\" name=\"KS_jianshu\"></textarea>  </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>  </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></tr>')
document.writeln('</table>')
document.writeln('</form>')