document.writeln('<table width=\"100%\" border=\"0\" cellspacing=\"2\" cellpadding=\"1\">')
document.writeln('<form name=\"myform\" action=\"/plus/form.asp\" method=\"post\"> ')
document.writeln('<input type=\"hidden\" value=\"Save\" name=\"action\">')
document.writeln('<input type=\"hidden\" value=\"4\" name=\"id\">')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">时间：</td>')
document.writeln('  <td><input type=\"text\" class=\"upfile\" style=\"width:150px\" name=\"KS_time\" value=\"\"><font color=\"red\"> * </font> <span style=\"margin-top:5px\"><a href=\'#\' onClick=\"OpenThenSetValue(\'/user/DateDialog.asp\',160,170,window,$(\'KS_time\'));$(\'KS_time\').focus();\"><img src=\'/Images/date.gif\' border=\'0\' align=\'absmiddle\' title=\'选择日期\'></a><br>【请点选日历，至少一日前预约】</span>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">姓名：</td>')
document.writeln('  <td><input type=\"text\" class=\"upfile\" style=\"width:150px\" name=\"KS_xingming\" value=\"\"><font color=\"red\"> * </font>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">手机：</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"11\"  class=\"upfile\" style=\"width:150px\" name=\"KS_shouji\" value=\"\"><font color=\"red\"> * </font>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">项目：</td>')
document.writeln('  <td><select class=\"upfile\" style=\"width:150px\" name=\"KS_xiangmu\"><option value=\"体检项目（男）\">体检项目（男）</option><option value=\"体检项目（女）\">体检项目（女）</option><option value=\"体检半价优惠套餐\">体检半价优惠套餐</option><option value=\"综合基本套餐\">综合基本套餐</option><option value=\"妇女体检项目\">妇女体检项目</option></select><font color=\"red\"> * </font>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">备注：</td>')
document.writeln('  <td><textarea style=\"width:150px;height:50px\" rows=\"5\" name=\"KS_beizhu\"></textarea>  </td>')
document.writeln('</tr>')
document.writeln('<tr class=\"tdbg\"><td class=\"lefttdbg\" align=\"right\">验证码：</td><td><input name=\"Verifycode\" type=\"text\" name=\"textbox\" size=5><IMG style=\"cursor:hand\" src=\"/KS_Inc/verifycode.asp\" onClick=\"this.src=\'/ks_inc/verifycode.asp?n=\'+ Math.random();\" align=\"absmiddle\"></td></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('</form>')
document.writeln('</table>')
document.writeln('')