See If You Qualify

Pre-Screener


Inquiry Form

open
FALCON

Are you a physician?

Eligibility Pre-Screener

Consent to Process Personal Information, Including Personal Health Information

As described in our Privacy Notice, when contacting Reata about medical inquiries, we require your explicit consent to process your personal information, including personal health information, which will be used by Reata to communicate with you and with third parties in the context of clinical trials. You have the right to withdraw your consent at any time without negative consequence. Upon your request for deletion, your data will be deleted from our files and the third parties’ clinical trial files.

Please tick to mark your consent and agreement:

Yes, I agree to have my personal information, including personal health information, used to communicate with me.

Yes, additionally, I agree that Reata may share my personal information, including personal health information, with third parties in the context of relevant clinical trials or as otherwise set forth in our Privacy Notice.

Yes, additionally, I agree that Reata may use my personal information to keep me informed about Reata’s trials or other activities Reata believes may be of interest to me.

*RA European Economic Area data subject is deemed not to have agreed to the language in this box as Reata has a legitimate interest to process the data of such subject in order to respond to the subject’s request or inquiry.

To see if you may qualify for participation in FALCON, please answer the following questions to the best of your ability. This should take approximately 5 minutes. The information you provide will be used ONLY for the purpose of determining your potential eligibility for the study.

1. Are you between the ages of 18 and 70 years old?

2. Have you been diagnosed with ADPKD?
3. Are you currently pregnant or breastfeeding?

4. Have you had a renal transplant?

5. Has your doctor told you that you have heart failure and/or heart diseases of your valves and/or diseases of the sac surrounding the heart?

6. Have you been diagnosed with any of the following?
Myocardial infraction (heart attack)

Percutaneous coronary intervention (procedure used to open blocked coronary arteries)

Coronary artery bypass graft surgery

Angina (chest pain)

7.Have you ever been hospitalized for heart failure?

8. Have you ever taken bardoxolone methyl, an investigational drug, for the treatment of various diseases such as pulmonary hypertension, kidney disease, etc.?

9. Are you currently taking (or have taken in the past) the prescription drug tolvaptan such as Samsca, or Jynarque?

10. Have you ever been on acute (short term) dialysis?

11. Has a doctor ever told you that you've had an acute kidney injury?

12. Please provide the name of the doctor currently treating your ADPKD. If you are unsure, please leave blank.


13. Please tell us how you heard about FALCON.

Web Ads or Google Searches

Facebook or other social media

PKD Foundation

NephCure

National Kidney Foundation

My Physician

Other, please specify


14. Please provide your contact information so we can reach out if you qualify for in-person screening visits. As a reminder, your information will not be used for other purposes.