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Regulations for medical spas in Texas

See case study “Failure to supervise aesthetician”

Many medical liability cases involving medical spas are linked to the improper supervision of those performing procedures.

Physicians who delegate duties are vicariously liable for the activities performed by staff members. In addition to rules on standing delegation orders and supervision of non-physician practitioners, the Texas Medical Board has established guidelines for non-surgical medical cosmetic procedures to be performed by a qualified non-physician.

These procedures include injections and the use of prescription medical devices for cosmetic purposes. Some treatments, such as laser hair removal and the use of nonprescription devices, are excluded from these rules. (1) Physicians who delegate performance of non-surgical cosmetic procedures should review TMB Rule 193.17 .

According to the TMB, these procedures must be performed while a physician or other mid-level practitioner is on site, or a physician must be available for an emergency consult or appointment if a complication occurs. Mid-level practitioners and non-physicians can only perform procedures under proper, required physician supervision. (1)

Before a procedure, the physician or supervised mid-level practitioner must do the following:

  • obtain a patient history and perform an appropriate physical examination;
  • appropriately diagnose and recommend treatment;
  • develop a detailed, written treatment plan;
  • obtain the patient’s informed consent;
  • provide instructions for emergency and follow-up care;
  • prepare and maintain an appropriate medical record;
  • have signed and dated written protocols; and
  • have signed and dated written standing orders.

The supervising physician must also ensure the individuals performing procedures have received appropriate training in the following areas:

  • techniques for each procedure;
  • cosmetic or cutaneous medicine;
  • procedural indications and contraindications;
  • pre-procedural and post-procedural care;
  • recognition and acute management of potential complications; and
  • infectious disease control involved in each treatment. (1)

Regardless of who performs the procedure, the supervising physician is responsible for the safety of the patient and for all aspects of the procedure. The physician should also ensure the procedure is documented and, if performed by unlicensed personnel, should co-sign the documentation.



1. Texas Medical Board. Texas Medical Board Rule 193.17. Nonsurgical medical cosmetic procedures. Available at