At a Physician Owned Medi-Spa, is a Registered Nurse Allowed to Administer Botox Without Ever Being Evaluated or Seen by the M.D

I live in CA where "Medi-Spas" are everywhere. I recently had Botox by an RN, leaving me with an inquisitive look on the right side of my face. I have never seen the physician, not even for a consult. At the same time, I had pixel laser done as well. Is this nurse allowed to perform these procedures without direct doctor supervision.....and not ever being consulted by a physician at all?

Doctor Answers 12

Legality and Safety of Nurse and Injector administered Botox in a Medi-Spa

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Botox and fillers are a multi-Billion dollars business. Like all such money making opportunities, it attracted a huge number of people who are more concerned with mining as much money from an uneducated and credulent public as is possible. For their part, while the many state Medical Boards and other regulatory bodies would be expected to uphold the public's safety above all considerations, they have not really done so. I'll let you consider for a moment why that has not been the case.

At the present time, each state has a different way of defining how much independence nurses and injectors have in performing Botox and filler injections (as well as laser procedures) and  how much supervision, real or imaginary, a doctor must give them.

In many states, a spa must have a licensed MD as a medical director. BUT his supervision may vary from his examining each patient and then allowing the RN or injector to actually perform the procedures TO his NEVER seeing any of the patients and being "off site" collecting a check for the use of his name. I get letters monthly from spas asking me to become a medical director.

PERSONALLY, in our practice in Memphis, TN, my partner and I do ALL of our Botox and fillers. We do not delegate it to nurses and injectors. I believe our results are superior to anything out there and our rates are competitive. I therefore cannot understand WHY would any intelligent woman be willing to get "treated" by an injector at a "MediSpa".

Please, do your homework.

Peter A Aldea, MD
Memphis, TN

Memphis Plastic Surgeon

Botox by a nurse

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Each state is a bit different.  A nurse can perform injections but the doctor should be evaluating the patient and discussing the treatment protocol. I inject all patients myself in my practice.

Treatment by an RN

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In NY, it would be illegal for you to be treated by a nurse wtihout physician evaluation and physical presence in the location at the time of treatment. There are many, many board certified plastic surgeons and dermatologists out there and so I must say that it is buyer beware for anyone who chooses to undergo a procedure at the hands of anyone with lesser credentials. This constitutes the unauthorized practice of medicine in many states.

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It depends on the state you receive your treatments

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Some states allow to have a nurse practitioner or PA inject the patients with out the doctor supervising. I personally treat all my patients myself. The decision about getting injected by a nurse or PA is up to the patient comfort with being treated by a non physican. Usually the price is lower which is another consideration. What ever you decide make sure the person is experienced and has good reviews about them.


Good luck!

Physican owned med spas

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Frankly, it depends on the state where this is occurring. Most of the time I will say this: a med spa needs to have a "medical director" who is a physician. This person does not need to be onsite, and in fact, sometimes they can never have even seen the medical spa, but merely collect a check for their "supervision". It's really a crazy way to get around the rules, but it happens more often that I'd like to say. I have a med spa, where I review every patient's chart daily, I see the patients pre and post and during their treatments, and they have full access to me anytime. Most medical spas in my city are NOT like this - few are. In California, RNs are licensed to inject and to perform treatments under the "supervision" of a physician. But that person may never have been around, and frankly, may not even know the RN at all. It's sad, but it happens. Find an office or med spa where the physician is onsite and you have full access to him/her all the time!

Sometimes common sense has to trump state laws where your safety and health is concerned: Botox and nurses at Medispas.

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Your question about whether it is legitimate for an RN nurse to inject your Botox at a California medspa without you having been evaluated even once by a physician is a great question. The answer is that state by state, laws may vary over exactly how much "supervision" of a nurse is legally required (sometimes "supervision" means the "medical director" has to have his name on a piece of paper but never be on site). This should in NO WAY determine the final decision you make about what is safest for you. Laws set the minimum standards, and in some cases, unfortunately, are formed by not fully educated lawmakers, or lawmakers influenced by many variables who are trying to balance opposing forces (spa small business interests vs. restriction of trade for safety reasons). Just because something is variably legal, does not mean you shouldn't question it when it's being done to you.

Nurse injections of botulinum toxin

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That's depends on the state you live in.  In Florida, Botox can only be done by a Physician or a Nurse Practioner / Physician's Assistant.  A nurse is not allowed to inject Botox.  Unfortuantely, a lot of Med Spas don't adhere to this.

Nurse injections of Botulinum toxin

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As you can tell, each state is different. The tightest standards have come from states like NY, NJ, CA and FL, where supply and demand dictate legislation sooner than states like where I practice in Wisconsin.  It's embarrassing to even write this, but in WI a nurse can do the injections as long as they are "under supervision", a term that is not defined.  And that supervision can take place with a medical director that is within 100 miles of the clinic dispensing botox.  That supervising doc can be an MD in nearly any field.  Its crazy, and unfortunate.  That's why we continue to push for legislation for stricter supervision, and by medical directors of the core disciplines of facial plastic surgery, general plastic surgery, oculoplastic surgery, and dermatology.

RN Administering Botox

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This is a State dependent question.  The best way to look it up in California is to review the CA Board of Nursing website.  In Florida, injection of Botox and/or fillers is deemed the practice of Medicine and an RN is not allowed to perform these procedures even when a Physician is present.  NP's and PA's are allowed to perform these procedures under protocols written and reviewed by the supervising Physician.  Aside from all of this, most consumers/ patients prefer that a Board Certified Facial Plastic Surgeon, Plastic Surgeon or Dermatologist perform this procedure themselves. 


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There are many RN's that are trained by their doctor to do injections of botox.  If that doctor trusts

his nurse's ability, then it is his decision to allow the to do injections.  It certainly is not against the

law.  Personally, I do my own injections, but that is my decision.  I feel that it gives my patients

confidence that they will get the best result.

E. Anthony Musarra II, MD
Atlanta Plastic Surgeon

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.