Confirmation of moveUP subscription – Support orthopedics

FOR 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.

Your country?*

In which hospital will you be having your surgery? (BE-NL)*

In which hospital will you be having your surgery? (BE-FR)*

In which hospital will you be having your surgery? (NL-NL)*

In which hospital will you be having your surgery? (EN-UK)*

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?

AZ Alma

Did you receive an email for approval to participate in the study?*

Yes
No

Which group were you assigned to?*

Possibility of using the mobile application WITHOUT a predetermined number of physiotherapy sessions
Possibility of using the mobile application WITH a predetermined number of physiotherapy sessions

Did you watch the video explaining the moveUP application?*

Yes
No

Was the explanation of the moveUP application clear to you?*

Yes
No

AZ Maria Middelares

Will 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

United Kingdom

Do you have access to Paypal for payments?*

Yes
No

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

Which brand of activity tracker do you have?*

Withings
Garmin

The activity tracker will be charged as a warranty. If you wish you can sent it back to us at the end of your treatment by normal post and we will transfer the amount (69,99 euro) back to you. On which IBAN number can we refund the amount?

Address*

First line Second line City ZIP / Postal Code Country

Pricing moveUP

The 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 moveUP

Please 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

Unless otherwise stated (one group in telerehabilitation study) it is not possible to combine moveUP and physical session in the presence of a physiotherapist in the same week. In the case you also go to a physical session, moveUP will not be reimbursed for that week and will cost you 40 euro a week.

I read this and I acknowledge in case I go to another fysiotherapist during the use of moveUP, this will cost me 40 euro that week.

What is the name of your private health insurer (including department)?*

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 you filled out to be able to order the activity tracker and preparing the moveUP subscription. The moveUP subscription is final when you have registered in the app.