document.writeln('<iframe src=\"about:blank\" name=\"hidform37\" 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=\"myform\" action=\"/plus/form/form.asp\" onSubmit=\"return(form_c());\"  target=\"hidform37\" 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=\"37\" 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=\"formstrck\" id=\"患者姓名|%|KS_xingming|%|1\" style=\"display:none\"></span><font color=\"red\"> * ')
document.writeln('</font> <span style=\"margin-top:5px\">请填植入者姓名</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\" ')
document.writeln('value=\"\"><span class=\"formstrck\" id=\"年龄|%|KS_nianling|%|1\" style=\"display:none\"></span><font color=\"red\"> * </font>  ')
document.writeln('</td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">居住城市</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:100px\" id=\"KS_juzhudi\" name=\"KS_juzhudi\" value=\"\">')
document.writeln('<span class=\"formstrck\" id=\"居住城市|%|KS_juzhudi|%|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\">手机号码</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=\"formstrck\" id=\"手机号码|%|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_weixin\" name=\"KS_weixin\" value=\"\">  ')
document.writeln('</td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">SPrint？</td>')
document.writeln('  <td><input type=\"radio\" id=\"KS_n6\" name=\"KS_n6\" value=\"是\">是<input type=\"radio\" id=\"KS_n6\" name=\"KS_n6\" value=\"否\">否')
document.writeln('<span class=\"formstrck\" id=\"SPprint？|%|KS_n6|%|6\" style=\"display:none\"></span><font color=\"red\"> * </font> <span ')
document.writeln('style=\"margin-top:5px\">限SPrint用户才能申请</span>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">经济条件</td>')
document.writeln('  <td><input type=\"radio\" id=\"KS_jiatingtiaojian\" name=\"KS_jiatingtiaojian\" value=\"殷实\">殷实<input type=\"radio\" ')
document.writeln('id=\"KS_jiatingtiaojian\" name=\"KS_jiatingtiaojian\" value=\"小康\">小康<input type=\"radio\" id=\"KS_jiatingtiaojian\" ')
document.writeln('name=\"KS_jiatingtiaojian\" value=\"普通\">普通<input type=\"radio\" id=\"KS_jiatingtiaojian\" name=\"KS_jiatingtiaojian\" ')
document.writeln('value=\"困难家庭\">困难家庭<span class=\"formstrck\" id=\"经济条件|%|KS_jiatingtiaojian|%|6\" style=\"display:none\"></span>')
document.writeln('<font color=\"red\"> * </font>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">备注说明</td>')
document.writeln('  <td><textarea style=\"width:200px;height:150px\" rows=\"5\" id=\"KS_shuoming\" name=\"KS_shuoming\"></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>')
document.writeln('')