<html>

<head>
<meta http-equiv=Content-Type content="text/html; charset=UTF-8">
<meta name=Generator content="Microsoft Word 15 (filtered)">
<style>
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</style>

</head>

<body lang=ZH-CN style='word-wrap:break-word;text-justify-trim:punctuation'>

<div class=WordSection1 style='layout-grid:15.6pt'>

<p class=MsoNormal align=center style='text-align:center;line-height:150%'><b><span
lang=EN-US style='font-size:18.0pt;line-height:150%'>${companyName}</span></b></p>

<table class=MsoTableGrid border=0 cellspacing=0 cellpadding=0 width=713 style='border-collapse:collapse;border:none'>
 <tr>
  <td width=238 valign=top style='width:178.2pt;padding:0cm 5.4pt 0cm 5.4pt'>
  <p class=MsoNormal align=left style='text-align:left'><span style='font-family:
  宋体'>姓</span><span lang=EN-US>&nbsp;&nbsp;&nbsp; </span><span
  style='font-family:宋体'>名：</span><span lang=EN-US>${patient.patientName!}</span></p>
  </td>
  <td width=238 colspan=2 valign=top style='width:178.2pt;padding:0cm 5.4pt 0cm 5.4pt'>
  <p class=MsoNormal align=left style='text-align:left'><span style='font-family:
  宋体'>性</span><span lang=EN-US>&nbsp;&nbsp;&nbsp; </span><span
  style='font-family:宋体'>别：</span><span lang=EN-US>
   <#if patient.sex?? && patient.sex==1>男</#if>
   <#if patient.sex?? && patient.sex==2>女</#if>
  </span></p>
  </td>
  <td width=238 valign=top style='width:178.25pt;padding:0cm 5.4pt 0cm 5.4pt'>
  <p class=MsoNormal align=left style='text-align:left'><span style='font-family:
  宋体'>年</span><span lang=EN-US>&nbsp;&nbsp;&nbsp; </span><span
  style='font-family:宋体'>龄：</span><span lang=EN-US style='font-family:"Times New Roman",serif'>${patient.age!}</span></p>
  </td>
 </tr>
 <tr>
  <td width=238 valign=top style='width:178.2pt;padding:0cm 5.4pt 0cm 5.4pt'>
  <p class=MsoNormal align=left style='text-align:left'><span style='font-family:
  宋体'>出生日期：</span><span lang=EN-US style='font-family:"Times New Roman",serif'>
   <#if patient.birthday??>${patient.birthday?string("yyyy-MM-dd")}</#if>
  </span></p>
  </td>
  <td width=238 colspan=2 valign=top style='width:178.2pt;padding:0cm 5.4pt 0cm 5.4pt'>
  <p class=MsoNormal align=left style='text-align:left'><span style='font-family:
  宋体'>民</span><span lang=EN-US>&nbsp;&nbsp;&nbsp; </span><span
  style='font-family:宋体'>族：</span><span lang=EN-US>${patient.nationality!}</span></p>
  </td>
  <td width=238 valign=top style='width:178.25pt;padding:0cm 5.4pt 0cm 5.4pt'>
  <p class=MsoNormal align=left style='text-align:left'><span style='font-family:
  宋体'>婚</span><span lang=EN-US>&nbsp;&nbsp;&nbsp; </span><span
  style='font-family:宋体'>姻：</span><span lang=EN-US>
   <#if patient.marriage??>
      <#if patient.marriage==1>未婚</#if>
      <#if patient.marriage==2>已婚</#if>
      <#if patient.marriage==3>丧偶</#if>
      <#if patient.marriage==4>离婚</#if>
   </#if>
  </span></p>
  </td>
 </tr>
 <tr>
  <td width=238 valign=top style='width:178.2pt;padding:0cm 5.4pt 0cm 5.4pt'>
  <p class=MsoNormal align=left style='text-align:left'><span style='font-family:
  宋体'>电</span><span lang=EN-US>&nbsp;&nbsp;&nbsp; </span><span
  style='font-family:宋体'>话：</span><span lang=EN-US style='font-family:"Times New Roman",serif'>${patient.patientPhone!}</span></p>
  </td>
  <td width=238 colspan=2 valign=top style='width:178.2pt;padding:0cm 5.4pt 0cm 5.4pt'>
  <p class=MsoNormal align=left style='text-align:left'><span style='font-family:
  宋体'>工作单位：</span><span lang=EN-US>${patient.workUnit!}</span></p>
  </td>
  <td width=238 valign=top style='width:178.25pt;padding:0cm 5.4pt 0cm 5.4pt'>
  <p class=MsoNormal align=left style='text-align:left'><span style='font-family:
  宋体'>职</span><span lang=EN-US>&nbsp;&nbsp;&nbsp; </span><span
  style='font-family:宋体'>业：</span><span lang=EN-US>${patient.occupation!}</span></p>
  </td>
 </tr>
 <tr>
  <td width=356 colspan=2 valign=top style='width:267.3pt;padding:0cm 5.4pt 0cm 5.4pt'>
  <p class=MsoNormal align=left style='text-align:left'><span style='font-family:
  宋体'>联系人电话：</span><span lang=EN-US style='font-family:"Times New Roman",serif'>${patient.linkPhone!}</span></p>
  </td>
  <td width=356 colspan=2 valign=top style='width:267.35pt;padding:0cm 5.4pt 0cm 5.4pt'>
  <p class=MsoNormal align=left style='text-align:left'><span style='font-family:
  宋体'>联系人姓名</span><span lang=EN-US>(</span><span style='font-family:宋体'>与患者关系</span><span
  lang=EN-US>)</span><span style='font-family:宋体'>：</span><span lang=EN-US>${patient.personalRelationship!}</span></p>
  </td>
 </tr>
 <tr>
  <td width=713 colspan=4 valign=top style='width:534.65pt;padding:0cm 5.4pt 0cm 5.4pt'>
  <p class=MsoNormal align=left style='text-align:left'><span style='font-family:
  宋体'>现</span> <span style='font-family:宋体'>住</span> <span style='font-family:
  宋体'>址：</span><span lang=EN-US>${patient.homeAddress!}</span></p>
  </td>
 </tr>
 <tr height=0>
  <td width=238 style='border:none'></td>
  <td width=119 style='border:none'></td>
  <td width=119 style='border:none'></td>
  <td width=238 style='border:none'></td>
 </tr>
</table>
<hr/>
<table class=MsoTableGrid border=0 cellspacing=0 cellpadding=0 width=713 style='width:534.65pt;border-collapse:collapse;border:none'>
 <#if patient.listMap?? && (patient.listMap?size>0)>
 <#list patient.listMap?keys as key>
 <tr>
  <td width=111 valign=top style='width:83.3pt;padding:0cm 5.4pt 0cm 5.4pt'>
  <p class=MsoNormal style='text-align:justify;text-justify:distribute-all-lines'><span style='font-family:宋体'>${key}：</span></p>
  </td>
  <td width=602 valign=top style='width:451.35pt;padding:0cm 5.4pt 0cm 5.4pt'>
  <p class=MsoNormal><span lang=EN-US>
  <#assign list = patient.listMap[key]!>
  <#if list?? && (list?size>0)>
      <#list list as li>
          <p><span>${li.toothPosition!} ${li.contentInfo!}</span></p>
      </#list>
  </#if>
  </span></p>
  </td>
 </tr>
</#list>
</#if>
</table>
<div style="page-break-after: always;"></div>
<p class=MsoNormal><span style='font-family:宋体'>医生声明：</span></p>
<p class=MsoNormal style='text-indent:21.0pt'><span style='font-family:宋体'>我已告知患者将要进行的治疗方式、并发症和风险，可能存在的其他治疗方法并解答了患者对于此次治疗的相关问题。</span></p>
<table class=MsoTableGrid border=0 cellspacing=0 cellpadding=0 width=713
 style='width:534.65pt;border-collapse:collapse;border:none'>
 <tr>
  <td width=578 valign=top style='width:433.75pt;padding:0cm 5.4pt 0cm 5.4pt'>
  <p class=MsoNormal align=right style='text-align:right'><span
  style='font-family:宋体'>医生签字：</span></p>
  </td>
  <td width=135 valign=top style='width:100.9pt;padding:0cm 5.4pt 0cm 5.4pt'>
  <p class=MsoNormal align=left style='text-align:left'><span lang=EN-US>&nbsp;</span></p>
  </td>
 </tr>
 <tr>
  <td width=578 valign=top style='width:433.75pt;padding:0cm 5.4pt 0cm 5.4pt'>
  <p class=MsoNormal align=right style='text-align:right'><span
  style='font-family:宋体'>签名日期：</span></p>
  </td>
  <td width=135 valign=top style='width:100.9pt;padding:0cm 5.4pt 0cm 5.4pt'>
  <p class=MsoNormal align=left style='text-align:left'><span lang=EN-US>&nbsp;</span></p>
  </td>
 </tr>
</table>

<div style='border:none;border-bottom:solid windowtext 1.0pt;padding:0cm 0cm 0cm 0cm'>
<p class=MsoNormal style='border:none;padding:0cm'><span lang=EN-US>&nbsp;</span></p>
</div>

<p class=MsoNormal><span style='font-family:宋体'>患者声明：</span></p>
<p class=MsoNormal align=left style='text-align:left;text-indent:21.0pt'><span
style='font-family:宋体'>我已知晓以上内容，</span><u><span lang=EN-US>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></u><span lang=EN-US>&nbsp;(</span><span style='font-family:宋体'>填“同意”或“不同意”</span>
 <span lang=EN-US>)</span><span style='font-family:宋体'>实施该项医疗措施。</span></p>

<table class=MsoTableGrid border=0 cellspacing=0 cellpadding=0 width=713
 style='width:534.65pt;border-collapse:collapse;border:none'>
 <tr>
  <td width=579 valign=top style='width:434.45pt;padding:0cm 5.4pt 0cm 5.4pt'>
  <p class=MsoNormal align=right style='text-align:right'><span
  style='font-family:宋体'>患者或监护人或近亲签名：</span></p>
  </td>
  <td width=134 valign=top style='width:100.2pt;padding:0cm 5.4pt 0cm 5.4pt'>
  <p class=MsoNormal><span lang=EN-US>&nbsp;</span></p>
  </td>
 </tr>
 <tr>
  <td width=579 valign=top style='width:434.45pt;padding:0cm 5.4pt 0cm 5.4pt'>
  <p class=MsoNormal align=right style='text-align:right'><span
  style='font-family:宋体'>与患者关系：</span></p>
  </td>
  <td width=134 valign=top style='width:100.2pt;padding:0cm 5.4pt 0cm 5.4pt'>
  <p class=MsoNormal><span lang=EN-US>&nbsp;</span></p>
  </td>
 </tr>
 <tr>
  <td width=579 valign=top style='width:434.45pt;padding:0cm 5.4pt 0cm 5.4pt'>
  <p class=MsoNormal align=right style='text-align:right'><span
  style='font-family:宋体'>签名日期：</span></p>
  </td>
  <td width=134 valign=top style='width:100.2pt;padding:0cm 5.4pt 0cm 5.4pt'>
  <p class=MsoNormal><span lang=EN-US>&nbsp;</span></p>
  </td>
 </tr>
</table>
<div style="page-break-after: always;"></div>
<span lang=EN-US style='font-size:10.5pt;font-family:"Calibri",sans-serif'><br clear=all style='page-break-before:always'></span>
<p class=MsoNormal><span lang=EN-US>&nbsp;</span></p>
${patient.content!}
</div>
</body>
</html>
