Subscription form – Support bariatrics

Your country?*

What is the name of your hospital? (BE-NL)*

Do you participate in the behavioural change project?*

Which group did you choose?*

What is the name of your hospital? (BE-FR)*

Your treating surgeon recommends that you receive weekly supervision after your surgery from a specialised physiotherapist via the moveUP app. Teleconsultations (€40/week) will be used. These are fully reimbursed if no other physiotherapy program is combined.*

I agree.
I refuse to receive reimbursed physiotherapy follow up.

You will receive a monthly invoice and certificate. You hand this in to your mutuality and you will get the full amount reimbursed. More info about this in the app.

Your treating surgeon strongly recommends follow-up by a physiotherapist after your possible surgery. You can opt for the digital physical therapy follow-up via the moveUP app. Teleconsultations (€40/week) are used. These are fully reimbursed. Digital physical therapy CANNOT be combined with treatments for other pathologies.*

I agree.
I need physical therapy treatment for another pathology.
Not interested.

You will receive a monthly invoice and certificate. You hand this in to your mutuality and you will get the full amount reimbursed. More info about this in the app.

A multidisciplinary team (physical therapist, dietician, psychologist, bariatric coordinator and surgeon) will take care of your digital follow up. Teleconsultations (€40/week) are used. These are fully reimbursed. This CANNOT be combined with physical therapy treatments for other pathologies.*

I agree
I need physical therapy treatment for another pathology

You will receive a monthly invoice and certificate. You hand this in to your mutuality and you will get the full amount reimbursed. More info about this in the app.

Name*

First name Surname

Email*

Mobile phone number*

The use of an activity tracker is highly recommended to keep track of your daily activity. We recommend the Garmin Vivofit 4. You can order one below for a deposit of EUR 69,99. This will be refunded if you return the activity tracker. If you already have an activity tracker of the brand "Garmin" or "Withings", you don't need to purchase a new one. You can pair your current activity tracker with the app.*

I want to order an activity tracker with a deposit of EUR 69,99
I already have a Garmin/Withings activity tracker
I really don’t want to use an activity tracker

The use of an activity tracker is mandatory to keep track of your daily activity. We recommend the Garmin Vivofit 4. You can order one below for a deposit of EUR 69,99. This will be refunded if you return the activity tracker. If you already have an activity tracker of the brand "Garmin" or "Withings", you don't need to purchase a new one. You can pair your current activity tracker with the app.*

I want to order an activity tracker with a deposit of EUR 69,99
I already have a Garmin/Withings activity tracker

The activity tracker will be charged as a warranty. If you wish you can sent it back to us 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

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

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No

How would you like to ask your questions?*

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I would prefer to submit them in the box below

Your questions*

How do you feel about starting with moveUP?

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I'm neutral
I'm hesitant

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Confirmation moveUP subscription Bariatrics