Subscription form study Joren—Subscription form study 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.Your country?*Belgium - French speaking partBelgium - Dutch speaking partNetherlandsFranceUnited KingdomUnited StatesOtherIn which hospital will you be having your intervention? (BE-NL)*UZ BrusselAZ AlmaAZ DamiaanAZ DiestAZ RivierenlandAZ Sint-Jan BruggeAZ St-Lucas BruggeAZ Sint-BlasiusAZ HerentalsAZ Maria Middelares (Ghent)AZ MonicaJan YpermanRZ TienenSint-TrudoUZA WilrijkUZ GentOTHER HOSPITAL (NOT IN LIST)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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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.