document.writeln('<iframe src=\"about:blank\" name=\"hidform5\" 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=\"myform5\" action=\"/plus/form/form.asp\" onSubmit=\"return(form_c(5));\"  target=\"hidform5\" 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=\"5\" 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 height=\"40\" align=\"right\" class=\"lefttdbg\">就诊姓名：</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:300px\" id=\"KS_name\" name=\"KS_name\" value=\"\">  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td height=\"50\" align=\"right\" class=\"lefttdbg\">联系电话：</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:300px\" id=\"KS_tel\" name=\"KS_tel\" value=\"\">  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td height=\"50\" align=\"right\" class=\"lefttdbg\">预约日期：</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" id=\"KS_yydate\" class=\"upfile\" style=\"width:300px\"  name=\"KS_yydate\" ')
document.writeln('value=\"\">  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td height=\"50\" align=\"right\" class=\"lefttdbg\">情况描述：</td>')
document.writeln('  <td><textarea style=\"width:400px;height:100px\" rows=\"5\" id=\"KS_content\" name=\"KS_content\"></textarea>  </td>')
document.writeln('</tr>')
document.writeln('<tr class=\"tdbg\">')
document.writeln('<td height=\"50\" align=\"right\" class=\"lefttdbg\">验证码：</td>')
document.writeln('<td><input name=\"Verifycode\" id=\"Verifycode\" type=\"text\" name=\"textbox\" size=5><span style=\"color:#999\">请输入下图中的字符')
document.writeln('</span></td>')
document.writeln('</tr>')
document.writeln('<tr class=\"tdbg\">')
document.writeln('<td height=\"40\" align=\"right\" class=\"lefttdbg\"></td>')
document.writeln('<td><IMG style=\"cursor:pointer\" src=\"../plus/verifycode.asp\" onClick=\"this.src=\'../plus/verifycode.asp?')
document.writeln('n=\'+ ')
document.writeln('Math.random();\" ')
document.writeln('align=\"absmiddle\"></td>')
document.writeln('</tr>')
document.writeln('<tr class=\"tdbg\">')
document.writeln('<td height=\"90\"  class=\"lefttdbg\"></td>')
document.writeln('<td><input type=\"submit\" value=\"确认提交\" class=\"yySub\" name=\"submit1\"> </td>')
document.writeln('</tr>')
document.writeln('</table></div>')
document.writeln('</form>')
document.writeln('')