Confirmation of moveUP subscription – Support orthopedics

Step counter returned? (Amphia only)

Yes
No

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)*

What is the name of your hospital?*

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

Name*

First Last

Email*

Your mobile phone*

The use of a step counter is obligatory if you use the moveUP app. We use the Garmin Vivofit 4. If you already have a step counter of the brand "Garmin" or "Withings", you don't have to order a new one. You can couple the one you have to the app.*

I don't have one and want to order one
I have my own step counter so I don't want to order one
I have already received a step counter from moveup/the clinic so I don't want to order one

The step counter 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*

Street Address 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

Can you confirm you consulted the price of moveUP and agree with it?*

I consulted the price for the use of moveUP app and the step counter and agree with it

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

Do you still have questions about the use of the moveUP application?*

Yes
No

Do you want somebody of moveUP to give you a call?

Yes, I still have some questions and I want a call from moveUP
No, I don't have any questions or I will ask them through email

Your questions*

When do you want to be called?

You can call me anytime during working hours
I want to pick a specific day and hour, send me a booking link

How do you feel about starting with moveUP?

I'm excited!
I'm neutral
I'm hesitant

Remark (optional)