Regulations for medical spas in Texas

The Texas Medical Board (TMB) recently issued guidance to physicians about medical spas, IV hydration clinics, and other medical businesses that rely on physician delegation and supervision to offer services. The TMB reports continued encounters with businesses that have either no physician involvement or inadequate physician involvement.

“Your medical license is an extremely valuable commodity, and regardless of the business models that pop up, the basic rules that govern your license continue to exist and be enforced,” says Dr. Sherif Zaafran, Texas Medical Board President, in the February 2025 TMB Bulletin. “Ultimately, it is your responsibility to abide by the rules that govern your license.”

‍TMB rules

In addition to the TMB rules on standing delegation orders and supervision of non-physician practitioners, the TMB has established rules for non-surgical medical cosmetic procedures to be performed by a qualified non-physician.

These procedures include injections for cosmetic purposes (i.e. Botox), IV hydration therapy, colonic irrigation, the use of prescription medical device for cosmetic purposes; and using a device to administer a nonprescription drug, dangerous drug or controlled substance. (1)

Supervision

According to the TMB, these procedures must be performed while a physician, physician assistant (PA) or advanced practice registered nurse (APRN) is on site, or a physician, PA, or APRN must be immediately available for an emergency consult and if necessary, an emergency appointment with a physician. (2) Advanced practice providers and non-physicians can only perform procedures under proper, required physician supervision.

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To delegate these acts, a physician must be appropriately trained or familiar with and able to perform the medical act. Before a procedure, the physician or supervised advanced practice provider must do the following:

1. establish a practitioner-patient relationship
2. disclose the identity and title of the individual who will perform the delegated act;
3. complete and maintain an adequate medical record in accordance with Chapter 163 of the TMB rule;
4. ensure at least one person trained in basic life support is present while the patient is on site;
5. have signed and dated written protocols (reviewed annually); and
6. have a plan for addressing patient emergencies; (2,3)
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The supervising physician must also ensure the individuals performing delegated medical acts have received appropriate training in the following areas:

• techniques for each procedure;
• procedural contraindications;
• pre-procedural and post-procedural care;
• recognition and acute management of potential complications; and
• infectious disease control for each treatment. (2)

Regardless of who performs the procedure, the supervising physician is responsible for the safety of the patient and for all aspects of the procedure.

Required notices

TMB rules also require transparency about who is administering and overseeing these treatments in medical spas. Any individual, business, or facility providing any delegated acts are required to post the name and TMB license number of the delegating physician and a notice of how to file a complaint with the board in all public areas and treatment rooms.

Additionally, all staff performing a delegated act under TMB rule 169.28 must wear ID showing their name and credentials. (4) Advertising for a practice at a location that is not the physician’s primary practice location must disclose medical directorship, supervision, or delegation to non-physicians. (5)

For more information

• Texas Medical Board Standing Delegation Orders — Chapter 169
• Texas Medical Board Other Delegated Acts — Chapter 169 Subchapter E
• Case study: Failure to supervise aesthetician

Sources

1. Texas Administrative Code. Title 22. Examining Boards. Part 9. Texas Medical Board. Section 169.25. Other Delegation.
2. Texas Administrative Code. Title 22. Examining Boards. Part 9. Texas Medical Board. Section 169.26. General Standards.
3. Texas Administrative Code. Title 22. Examining Boards. Part 9. Texas Medical Board. Section 169.2. General Responsibilities of Delegating Physician.
4. Texas Administrative Code. Title 22. Examining Boards. Part 9. Texas Medical Board. Section 169.28. Notice and Identification Provisions.
5. Texas Administrative Code. Title 22. Examining Boards. Part 9. Texas Medical Board. Section 164.3. Prohibited Acts or Omissions in Advertising.

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