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

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.

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.

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. 

If your injector was a nurse practitioner or a physicians assistant (PA), these individuals may perform treatment independent of the supervising physician when operating under a written protocol.  The notes and treatment by the PA must be reviewed by the supervising physician.  I am not sure if this applies to a nurse practitioner.  However, in the State of California, a registered nurse can only perform a Botox treatment if there has been a good faith examination by the physician and the physician is on the premises at the time of the treatment.  If this is not the case and you had an adverse treatment, it is reasonable to report the Medspa, the nurse, and the "supervising physician" to the California Medical Board.  They are understaffed and can't track down all these bogus situations without the cooperation of the public.

Hello. You are correct in assuming that you should be seen or evaluated by the MD first, at least in California.

While RNs are allowed to inject Botox in California under the supervision of a physician, they are not allowed to offer a prescription. Because Botox is a prescriptive pharmaceutical, any nurse injecting it prior to a physician exam is breaking the law.

The problem is that this law is broken many, many times every day by medi-spas and traditional medical practices every day.

The exception to this would be if your injector is a nurse practitioner or a physician assistant. Each of these two can offer Botox and provide the prescription without the MD exam.