COVID Vaccine Interest Form - Priority Group 1B.1

Priority Group 1B.1: Please sign up here if you are 65+ and EITHER live in Wise County OR are a patient of Wise Health System or Wise Health Clinics.

By submitting this form, I am attesting that I qualify as a Texas DSHS phase 1B priority group based on the criteria indicated below. If I am a patient of Wise Health System or Wise Health Clinics, I give permission to review my health record as needed for confirmation of my health issues that qualifies me for this 1B Category and approves the vaccine information to be sent to the State of Texas ImmTrac Registry.