Subscription form study – 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.

Your country?*

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

Name*

First name Surname

Email*

Mobile phone number*

The activity tracker is offered completely free of charge thanks to the study in which you participate, set up by Vrije Universiteit Brussel in collaboration with UZ Brussel.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

! No other brands than Garmin or Withings are compatible

Which brand of activity tracker do you have?*

Withings
Garmin

Address*

First line Second line City ZIP / Postal Code Country

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.

Joren—Subscription form study