Confirmation of moveUP subscription – Support orthopedics

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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.

What will you use moveUP for?*

Your country?*

In which hospital will you be treated? (BE-NL)*

In which hospital will you be treated? (BE-FR)*

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 Alma

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

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 Country

Pricing moveUP and activity tracker

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

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.