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<p style="text-align: center;">
<span style="font-family: 微软雅黑, "Microsoft YaHei"; font-size: 24px;"><strong>就医/体验服务申请单</strong></span>
</p>
<table width="715" align="center" class="td-min-height" id="table1" style="border: 1px solid rgb(49, 133, 155); width: 631px; table-layout: fixed;" border="1" data-sort="sortDisabled">
<tbody>
<tr class="firstRow">
<td align="left" valign="center" style="border: 1px solid rgb(146, 205, 220); height: 30px; text-align: left; background-color: rgb(183, 221, 232);" rowspan="1" colspan="5">
<span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";"><strong> 提需人填写：</strong></span>
</td>
</tr>
<tr>
<td align="left" valign="center" style="border-color: rgb(146, 205, 220); height: 30px; text-align: left; border-right-style: solid; border-bottom-style: solid; border-image: initial;" rowspan="1" colspan="5">
<p>
<span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";"> <strong>客户所属：</strong><input type="checkbox" name="DATA_515" title="公关"/>公关 <span style="font-family: 微软雅黑, "Microsoft YaHei"; font-size: 12px;">项目号：<input type="text" name="DATA_606" align="left" hidden="0" title="项目号" style="font-size:12px;width:100px;text-align:left;"/> </span>企业名称：<input type="text" name="DATA_516" align="left" hidden="0" title="企业名称" style="font-size:12px;text-align:left;width:200px;" value=""/></span>
</p>
<p>
<span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";"> 项目金额：<input type="text" name="DATA_517" align="left" hidden="0" title="项目金额" style="font-size:12px;width:100px;text-align:left;"/>元 签单时间：<input type="text" name="DATA_518" align="left" hidden="0" title="签单时间" style="font-size:12px;width:90px;text-align:left;"/><img title="日期控件:签单时间" value="签单时间" date_format="yyyy-MM-dd" border="0" align="absMiddle" class="DATE" classname="DATE" src="/static/images/form/calendar.png" style="cursor: pointer;width:18px;height:18px;" alt="" name="OTHER_519"/></span>
</p>
</td>
</tr>
<tr>
<td valign="center" align="left" style="border-color: rgb(146, 205, 220); height: 30px; text-align: left;" rowspan="1" colspan="5">
<span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";"><strong> 客户需求：</strong><input type="checkbox" name="DATA_520" title="取号"/>取号 <input type="checkbox" name="DATA_522" title="挂号"/>挂号 <input type="checkbox" name="DATA_524" title="挂号+导诊"/>挂号+导诊 <input type="checkbox" name="DATA_526" title="住院"/>住院 <input type="checkbox" name="DATA_528" title="专家会诊"/>专家会诊 <input type="checkbox" name="DATA_530" title="优先就诊"/>优先就诊 <input type="checkbox" name="DATA_532" title="体检"/>体检</span>
</td>
</tr>
<tr>
<td valign="center" align="left" style="border-color: rgb(146, 205, 220); height: 30px; text-align: left;" rowspan="1" colspan="5">
<span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";"> 医院：<input type="text" name="DATA_539" align="left" hidden="0" title="医院" style="font-size:12px;width:120px;text-align:left;"/> 科室：<input type="text" name="DATA_540" align="left" hidden="0" title="科室" style="font-size:12px;width:120px;text-align:left;"/> 专家：<input type="text" name="DATA_541" align="left" hidden="0" title="专家" style="font-size:12px;width:120px;text-align:left;"/> 接受特需：<select title="是否接受特需" name="DATA_542"><option value="是">
是
</option>
<option value="否">
否
</option>
<option value="" selected="selected"></option></select></span>
</td>
</tr>
<tr>
<td valign="center" align="left" style="border-color: rgb(146, 205, 220); height: 30px; text-align: left;" rowspan="1" colspan="5">
<span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";"> 预约时间：<input type="text" name="DATA_543" align="left" hidden="0" title="预约时间" style="font-size:12px;width:100px;text-align:left;"/><img title="日期控件:预约时间" value="预约时间" date_format="yyyy-MM-dd" border="0" align="absMiddle" class="DATE" classname="DATE" src="/static/images/form/calendar.png" style="cursor: pointer;width:18px;height:18px;" alt="" name="OTHER_545"/> 会员卡号：<input type="text" name="DATA_544" align="left" hidden="0" title="会员卡号" style="font-size:12px;width:200px;text-align:left;"/></span><br/>
</td>
</tr>
<tr>
<td valign="center" align="left" style="border-color: rgb(146, 205, 220); height: 90px; text-align: center;">
<span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";"><strong> 公关内容</strong></span>
</td>
<td valign="center" align="left" style="border-color: rgb(146, 205, 220); height: 30px; text-align: left;" rowspan="1" colspan="4">
<textarea title="公关内容" rich="0" style="font-size: 12px; width: 481px; height: 92px; margin: 0px;" name="DATA_546"></textarea>
</td>
</tr>
<tr>
<td valign="center" align="left" style="border-color: rgb(146, 205, 220); height: 30px; text-align: center;">
<span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";"><strong> 协调费支付方式</strong></span>
</td>
<td valign="center" align="left" style="border-color: rgb(146, 205, 220); height: 30px; text-align: left;" rowspan="1" colspan="4">
<input type="checkbox" name="DATA_547" title="项目内支付"/><span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";">项目内支付 </span><input type="checkbox" name="DATA_549" title="客户承担"/><span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";">客户承担（如客户承担务必先付款）</span>
</td>
</tr>
<tr>
<td valign="center" align="left" style="border-color: rgb(146, 205, 220); height: 30px; text-align: left;" rowspan="1" colspan="5">
<span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";"> <strong>就诊人信息</strong></span>
</td>
</tr>
<tr>
<td valign="center" align="left" style="border-color: rgb(146, 205, 220); height: 30px; text-align: center;" rowspan="1" colspan="5">
<img title="就诊人信息" default_cols="2" border="0" name="DATA_600" alt="" align="absMiddle" lv_title="就诊/体验人姓名`性别`年龄`联系方式`有效证件号码`" lv_sum="0`0`0`0`0`" lv_field="1`2`3`4`5`" lv_size="150`70`80`100`156`" lv_colvalue="`,男,女````" lv_coltype="text`select`text`text`text`" lv_cal="`````" datatype="1" lv_value="1" new_width="true" class="LIST_VIEW" style="cursor: hand" src="/static/images/form/listview.png"/>
</td>
</tr>
<tr>
<td valign="center" align="left" style="border-color: rgb(146, 205, 220); height: 30px; text-align: center;">
<span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";">卡种类</span>
</td>
<td valign="center" align="left" style="border-color: rgb(146, 205, 220); text-align: left;" rowspan="1" colspan="4">
<input type="checkbox" name="DATA_610" id="box" title="实物卡"/><span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";">实物卡</span>
</td>
</tr>
<tr id="tr1">
<td valign="center" align="left" rowspan="1" colspan="1" style="border-color: rgb(146, 205, 220); height: 30px; text-align: center;">
<span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";">申请数量<br/></span>
</td>
<td valign="center" align="left" rowspan="1" colspan="1" style="border-color: rgb(146, 205, 220); text-align: left;">
<input type="text" name="DATA_608" align="left" hidden="0" title="卡数量" style="font-size:12px;width:60px;text-align:left;"/><span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";">张</span>
</td>
<td valign="center" align="left" rowspan="1" colspan="1" style="border-color: rgb(146, 205, 220); text-align: center;">
<span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";">卡号</span>
</td>
<td valign="center" align="left" rowspan="1" colspan="2" style="border-color: rgb(146, 205, 220); text-align: left;">
<input type="text" name="DATA_609" align="left" hidden="0" title="卡号" style="font-size:12px;width:200px;text-align:left;"/>
</td>
</tr>
<tr>
<td valign="center" align="left" style="border-color: rgb(146, 205, 220); height: 30px; text-align: left;" rowspan="1" colspan="5">
<span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";"> <strong>需求人类型：</strong><strong><input type="checkbox" name="DATA_560" title="管理层"/></strong>管理层 <input type="checkbox" name="DATA_562" title="管理层亲友"/>管理层亲友 <input type="checkbox" name="DATA_564" title="决策人"/>决策人 <input type="checkbox" name="DATA_566" title="决策人亲友"/>决策人亲友 <input type="checkbox" name="DATA_568" title="其他"/>其他（<input type="text" name="DATA_570" align="left" hidden="0" title="其他需求人" style="font-size:12px;width:100px;text-align:left;"/>）</span><br/>
</td>
</tr>
<tr>
<td valign="center" align="left" style="border-color: rgb(146, 205, 220); height: 30px; text-align: left;" rowspan="1" colspan="5">
<span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";"> 需求发起部门：</span><input title="需求发起部门" class="AUTO" datafld="SYS_DEPTNAME_SHORT" hidden="0" style="font-size: 12px;width: 120px;" name="DATA_571" value="{MACRO}" type="text"/><span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";"> 需求提交人：</span><input title="需求提交人" class="AUTO" datafld="SYS_USERNAME" hidden="0" style="width: 80px;" name="DATA_572" value="{MACRO}" type="text"/><span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";"> 提交日期/时间：</span><input title="提交日期" class="AUTO" datafld="SYS_DATE" hidden="0" style="width: 80px;" name="DATA_573" value="{MACRO}" type="text"/>
</td>
</tr>
<tr>
<td valign="center" align="left" style="border-color: rgb(146, 205, 220); height: 30px; text-align: left; background-color: rgb(183, 221, 232);" rowspan="1" colspan="5">
<span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";"> <strong>审批签字</strong></span>
</td>
</tr>
<tr>
<td valign="center" align="left" style="border-color: rgb(146, 205, 220); height: 80px; text-align: center;">
<span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";">部门负责人</span>
</td>
<td valign="center" align="left" style="border-color: rgb(146, 205, 220); height: 30px; text-align: left;" rowspan="1" colspan="4">
<p>
<span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";">客户星级：</span><input type="checkbox" name="DATA_595" title="二星" style="white-space: normal;"/><span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";">★★ </span><input type="checkbox" name="DATA_596" title="三星" style="white-space: normal;"/><span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";">★★★</span><input type="checkbox" name="DATA_597" title="四星" style="white-space: normal;"/><span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";">★★★★</span><input type="checkbox" name="DATA_598" title="五星" style="white-space: normal;"/><span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";">★★★★★</span>
</p>
<p>
<textarea title="部门负责人意见" rich="0" style="font-size: 12px;width: 460px;height: 50px;" name="DATA_574"></textarea>
</p>
<p style="text-align: right;">
<span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";">审批人：</span><input title="部门负责人签字" class="AUTO" datafld="SYS_USERNAME" hidden="0" style="font-size: 12px;width: 100px;" name="DATA_575" value="{MACRO}" type="text"/><span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";"> 审批时间：</span><input title="部门负责人审批时间" class="AUTO" datafld="SYS_DATE" hidden="0" style="font-size: 12px;width: 100px;" name="DATA_576" value="{MACRO}" type="text"/>
</p>
</td>
</tr>
<tr>
<td align="left" valign="center" colspan="1" rowspan="1" style="border-color: rgb(146, 205, 220); height: 80px; text-align: center;">
<span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";">财务负责人</span>
</td>
<td align="left" valign="center" colspan="4" rowspan="1" style="border-color: rgb(146, 205, 220); text-align: left;">
<p>
<textarea title="财务负责人审批意见" rich="0" style="width: 460px;height: 50px;" name="DATA_506"></textarea>
</p>
<p style="text-align: right;">
<span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";">审批人：</span><input title="财务审批人签字" class="AUTO" datafld="SYS_USERNAME" hidden="0" style="width: 100px;" name="DATA_507" value="{MACRO}" type="text"/><span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";"> 审批时间：</span><input title="财务负责人审批时间" class="AUTO" datafld="SYS_DATE" hidden="0" style="width: 100px;" name="DATA_508" value="{MACRO}" type="text"/>
</p>
</td>
</tr>
<tr>
<td valign="center" align="left" style="height: 80px; text-align: center; border-color: rgb(146, 205, 220);">
<span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";">销售负责人<br/></span>
</td>
<td valign="center" align="left" style="text-align: left; border-color: rgb(146, 205, 220);" rowspan="1" colspan="4">
<p>
<textarea title="销售负责人审批意见" rich="0" style="width: 460px;height: 50px;" name="DATA_503"></textarea>
</p>
<p style="text-align: right;">
<span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";">审批人：</span><input title="销售负责人审批人" class="AUTO" datafld="SYS_USERNAME" hidden="0" style="width: 100px;" name="DATA_504" value="{MACRO}" type="text"/><span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";"> 审批时间：</span><input title="销售负责人审批时间" class="AUTO" datafld="SYS_DATE" hidden="0" style="width: 100px;" name="DATA_505" value="{MACRO}" type="text"/>
</p>
</td>
</tr>
<tr>
<td align="left" valign="center" style="border-color: rgb(146, 205, 220); height: 80px; text-align: center; border-right-style: solid; border-bottom-style: solid; border-image: initial;">
<span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";">区域负责人</span>
</td>
<td align="left" valign="center" style="border-color: rgb(146, 205, 220); height: 30px; text-align: left; border-right-style: solid; border-bottom-style: solid; border-image: initial;" rowspan="1" colspan="4">
<p>
<textarea name="DATA_450" title="区域负责人审批意见" style="width: 460px;height: 50px;" rich="0"></textarea>
</p>
<p style="text-align: right;">
<span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";">审批人：</span><input title="区域负责人审批签字" class="AUTO" datafld="SYS_USERNAME" hidden="0" style="width: 100px;" name="DATA_451" value="{MACRO}" type="text"/><span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";"> 审批时间：</span><input title="区域负责人审批时间" class="AUTO" datafld="SYS_DATE" hidden="0" style="width: 100px;" name="DATA_452" value="{MACRO}" type="text"/>
</p>
</td>
</tr>
</tbody>
</table>
<p>
<span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";"> </span>
</p>
<p>
<span style="font-size: 12px; font-family: 微软雅黑, "Microsoft YaHei";"> </span>
</p>
07-14
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