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 TieltGZA 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 I would like to sync the built-in step counter on my phone with the moveUP app through Google Fit or Apple Health and will keep my phone with me during my activities 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 I would like to sync the built-in step counter on my phone with the moveUP app through Google Fit or Apple Health and will keep my phone with me during my activities 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? 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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 Kiest u voor moveUP als revaliatietraject voor uw knie of heup, dan gaat u niet naar een reguliere fysiotherapeut vanwege dezelfde aandoening/revalidatie. Ook niet als moveUP is afgesloten. 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 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.
