document.writeln('  <table class=f12 borderColor=#78c237 height=222 cellSpacing=0 cellPadding=1 width=710 align=center border=0>')
document.writeln('<FORM name=form1 onsubmit=\"\\"return\" action=http://www.zhifangliu.org/houtai/book/zflnet_FormAddOK.asp method=post target=_blank>')
document.writeln('    <tr>')
document.writeln('      <td bgColor=#78c237 colSpan=7 height=20>')
document.writeln('      <div class=ddt>填写电子病历即可体验专家免费会诊，并且免费获得《脂肪瘤防治手册》一本</div></td>')
document.writeln('    </tr>')
document.writeln('    <tr>')
document.writeln('      <td vAlign=center width=86 bgColor=#effcf1 height=32><SPAN class=t12>&nbsp;&nbsp;&nbsp;姓名：</SPAN></td>')
document.writeln('      <td vAlign=center width=102 bgColor=#effcf1 height=32>')
document.writeln('        <Input id=姓名 size=10 name=姓名> <font color=#ff0000>*</font></td>')
document.writeln('      <td vAlign=center width=120 bgColor=#effcf1 height=32><SPAN class=t12>性　别: ')
document.writeln('<Select class=4b id=select name=性别> ')
document.writeln('  <Option value=先生 selected>先生</Option> ')
document.writeln('  <Option value=女士>女士</Option>')
document.writeln('      </Select> </SPAN></td>')
document.writeln('      <td vAlign=center width=42 bgColor=#effcf1 height=32><SPAN class=t12>年龄：</SPAN></td>')
document.writeln('      <td vAlign=center width=94 bgColor=#effcf1 height=32>')
document.writeln('        <Input id=年龄 size=10 name=年龄></td>')
document.writeln('      <td vAlign=bottom align=left width=63 bgColor=#effcf1 height=32><SPAN class=t12>联系电话：</SPAN></td>')
document.writeln('      <td vAlign=bottom align=left width=159 bgColor=#effcf1 height=32>')
document.writeln('        <Input id=post_name size=13 name=联系电话> <font color=#ff0000>*</font></td>')
document.writeln('    </tr>')
document.writeln('    <tr>')
document.writeln('      <td vAlign=center bgColor=#effcf1 height=24><SPAN class=t12>&nbsp;&nbsp;&nbsp;联系地址：</SPAN></td>')
document.writeln('      <td vAlign=center bgColor=#effcf1 colSpan=4 height=24>')
document.writeln('        <Input id=通讯地址 size=48 name=通讯地址> <font color=#ff0000>*</font></td>')
document.writeln('      <td class=t12 vAlign=bottom align=left bgColor=#effcf1 height=24>邮编：</td>')
document.writeln('      <td vAlign=bottom align=left bgColor=#effcf1 height=24>')
document.writeln('        <Input id=邮政编码 size=13 name=邮政编码></td>')
document.writeln('    </tr>')
document.writeln('    <tr>')
document.writeln('      <td vAlign=center bgColor=#effcf1 height=24><SPAN class=t12>&nbsp;&nbsp;&nbsp;所患病症：</SPAN></td>')
document.writeln('      <td vAlign=center bgColor=#effcf1 colSpan=4 height=24>')
document.writeln('<Select name=病名> ')
document.writeln('  <Option value=脂肪瘤 selected>脂肪瘤</Option> ')
document.writeln('  <Option value=多发性脂肪瘤>多发性脂肪瘤</Option> ')
document.writeln('  <Option value=皮下脂肪瘤>皮下脂肪瘤</Option> ')
document.writeln('  <Option value=肝脏脂肪瘤>肝脏脂肪瘤</Option> ')
document.writeln('  <Option value=乳腺脂肪瘤>乳腺脂肪瘤</Option> ')
document.writeln('  <Option value=弥漫性脂肪瘤>弥漫性脂肪瘤</Option> ')
document.writeln('  <Option value=其他脂肪瘤>其他脂肪瘤</Option>')
document.writeln('      </Select> <font color=#ff0000>*</font></td>')
document.writeln('      <td class=t12 vAlign=bottom align=left bgColor=#effcf1 height=24>传真：</td>')
document.writeln('      <td vAlign=bottom align=left bgColor=#effcf1 height=24>')
document.writeln('        <Input class=4b id=SUPPER_MEMO size=13 name=SUPPER_MEMO></td>')
document.writeln('    </tr>')
document.writeln('    <tr vAlign=center>')
document.writeln('      <td bgColor=#effcf1 height=24><SPAN class=t12>&nbsp;&nbsp;&nbsp;病情描述：</SPAN></td>')
document.writeln('      <td bgColor=#effcf1 colSpan=6 height=24><TEXTAREA class=4b id=咨询问题 name=咨询问题 rows=4 wrap=VIRTUAL cols=70></TEXTAREA> <font color=#ff0000>*</font></td>')
document.writeln('    </tr>')
document.writeln('    <tr>')
document.writeln('      <td vAlign=center bgColor=#effcf1 height=30>&nbsp;</td>')
document.writeln('      <td vAlign=center bgColor=#effcf1 colSpan=4><LABEL>')
document.writeln('  <Input type=submit value=提　交 name=Submit> &nbsp;&nbsp;&nbsp;&nbsp; ')
document.writeln('  <Input type=reset value=重　填 name=Submit></LABEL> ')
document.writeln('        <Input id=来自媒体 type=hidden value=babyle123 name=来自媒体></td>')
document.writeln('      <td class=t12 bgColor=#effcf1 height=30>&nbsp;</td>')
document.writeln('      <td bgColor=#effcf1 height=30>&nbsp;</td>')
document.writeln('    </tr>')
document.writeln('</FORM>')
document.writeln('  </table>')
