document.writeln('<iframe src=\"about:blank\" name=\"hidform41\" 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=\"myform41\" action=\"/plus/form/form.asp\" onSubmit=\"return(form_c(41));\"  target=\"hidform41\" ')
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=\"41\" 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=\"formstrck41\" id=\"患者姓名|%|KS_xingming|%|1\" style=\"display:none\"></span><font ')
document.writeln('color=\"red\"> * </font> <span style=\"margin-top:5px\">请填全名,勿写小名</span>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">患者年龄</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:100px\" id=\"KS_nianling\" name=\"KS_nianling\" ')
document.writeln('value=\"\"><span class=\"formstrck41\" id=\"患者年龄|%|KS_nianling|%|1\" style=\"display:none\"></span><font ')
document.writeln('color=\"red\"> * </font>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">患者性别</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\">常驻省市</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:100px\" id=\"KS_juzhudi\" name=\"KS_juzhudi\" ')
document.writeln('value=\"\"><span class=\"formstrck41\" id=\"常驻省市|%|KS_juzhudi|%|1\" style=\"display:none\"></span><font ')
document.writeln('color=\"red\"> * </font> <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\">家长亲友或本人</span>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">手机号码</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:100px\" id=\"KS_shouji\" name=\"KS_shouji\" ')
document.writeln('value=\"\"><span class=\"formstrck41\" id=\"手机号码|%|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 class=\"formstrck41\" id=\"微信号码|%|KS_weixin|%|1\" style=\"display:none\"></span><font color=\"red\"> ')
document.writeln('* </font> <span style=\"margin-top:5px\">加群须有微信号</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:200px;height:150px\" rows=\"5\" id=\"KS_bingqingjianshu\" name=\"KS_bingqingjianshu\">')
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('')