Confirmation of moveUP subscription HiddenFOR ADMINISTRATION (hidden from patient): Activity tracker returned? Yes No Take care: this will create an email to the patient when you click save. Make sure the IBAN number is filled out correctly.What will you use moveUP for?*Knee/hipCOPD/BPCOYour country?*Belgium - French speaking partBelgium - Dutch speaking partNetherlandsFranceUnited KingdomUnited StatesOtherIn which hospital will you be treated? (BE-NL)*UZ BrusselAZ AlmaAZ DamiaanAZ DiestAZ RivierenlandAZ Sint-Jan BruggeAZ St-Lucas BruggeAZ Sint-BlasiusAZ HerentalsAZ Maria Middelares (Ghent)AZ MonicaAZ Jan YpermanRZ TienenSint-TrudoSint-Andries TieltUZA WilrijkUZ GentZNA MiddelheimOTHER HOSPITAL (NOT IN LIST)In which hospital will you be treated? (BE-FR)*CHC Montlégia LiègeChirec Braine-L’AlleudChirec DeltaChirec – St Anne St RemyCHU Brugmann – Paul BrienCHU LiègeGHDC CharleroiHôpital de Nivelles – JolimontHôpitaux ErasmeHôpitaux Iris SudSaint-Jean BruxellesSaint Luc BougeUCL Saint-LucCHU Namur Mont-GodinneCHU Namur St-ElisabethOTHER HOSPITAL (NOT IN LIST)What is the name of your hospital?* Do you take part in a study (did you sign an informed consent for a study) Yes No Which study? GEKO Evolution Navio REACTOME: Tele-rehabilitation of patients with an autologous stemcell transplantation I don't know AZ AlmaDid you watch the video explaining the moveUP application?* Yes No Was the explanation of the moveUP application clear to you?* Yes No AZ Maria MiddelaresWill you go to the knee and hip class info session of the AZ Maria Middelares hospital?* Yes No I already followed the hip and knee class Name* First name Surname Email* Mobile phone number* The use of an activity tracker is mandatory to use the moveUP app. You can order it below. We recommend the Garmin Vivofit 4. If you already have an activity tracker of the brand "Garmin" or "Withings", you do not need to purchase a new one. You can pair your current activity tracker with the app.* I don't have an activity tracker yet and would like to order I have my own Garmin/Withings activity tracker so I don't need to order one I have already received an activity tracker from moveup/the clinic so I don't need to order I have another brand of activity tracker and decided to report my steps manually in the app, without synchronisation possibility The use of an activity tracker is highly recommended to keep track of your daily activity. We can provide you with a Garmin Vivofit 4. We ask you to return them when you stop using moveUP* I don't have an activity tracker yet and would like to order I have my own Garmin/Withings activity tracker so I don't need to order one I have another brand of activity tracker and decided to report my steps manually in the app, without synchronisation possibility I have already received an activity tracker from moveup/the clinic so I don't need to order I really don’t want to use an activity tracker Which brand of activity tracker do you have?* Withings Garmin The activity tracker will be charged as a warranty (€69). If you wish you can sent it back to us at the end of your treatment by normal post and we will transfer the activity tracker amount back to you. On which bank account number can we refund the amount? Address* First line Second line City ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Pricing moveUP and activity trackerThe price for the use of moveUP and the activity tracker depends on your country and hospital. You can find your pricing on the following webpage: price moveUPPlease confirm you viewed the price page of moveUP and agree with it* I have reviewed the price for the use of the moveUP app and the activity tracker and I agree with it You will be guided and coached through the application by a team of physiotherapist and/or doctors. For this follow-up, telenomenclature will be charged to your health insurance fund for 40 euro per week. This will be charged directly to your health insurance fund and you will not have to pay for it. I read this and I agree It is not possible to combine moveUP and physical session in the presence of a physical therapist in the same week. In the case you also go to a physical session, moveUP will not be reimbursed for that week. I read this and I acknowledge in case I go to another physical therapist during the use of moveUP, moveUP will not be reimbursed for that week Included in the moveUP therapy plan is an in-person physical session with a physical therapist once a week for the first month after operation and once every 2 weeks thereafter I read this and I agree Do you still have any further questions about the use of the moveUP application?* Yes No How would you like to ask your questions? I would like moveUP to call me to discuss I would prefer to submit them in the box below Your questions*How do you feel about starting with moveUP? I'm excited! I'm neutral I'm hesitant Comments (optional)By pressing the Submit button, we will process the above data for your moveUP subscription. The moveUP subscription is final when you have registered in the app.