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TMB guidelines for medical spas

Editor's note: The Texas Medical Board will be issuing new rules for medical spas in the coming months. We will post these rule changes on this site as soon as they are available.

Medical spas are gaining in popularity, and Texas leads the nation with the most medical spas of any state. According to a report on the medical spa industry, these facilities are expected to increase revenues by 91 percent in 2019. The average profit margin for a medical spa was 29 percent in 2018. (1)

With the growing popularity of medical spas comes an increased risk of malpractice lawsuits for physicians who offer medical spa services within their practices. Many cases involving med spas are linked to the improper supervision of those performing procedures.

TMB rules

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 (TMB) 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 device for cosmetic purposes. Some treatments, such as laser hair removal and the use of nonprescription devices, are excluded from these rules. (2) Physicians who delegate performance of non-surgical cosmetic procedures should review TMB rule 193.17 in full.

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. (2)

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

  1. obtain a patient history and perform an appropriate physical examination;
  2. appropriately diagnose and recommend treatment;
  3. develop a detailed, written treatment plan;
  4. obtain the patient’s informed consent;
  5. provide instructions for emergency and follow-up care;
  6. prepare and maintain an appropriate medical record;
  7. have signed and dated written protocols; and
  8. 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.

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.


For more information



  1. American Med Spa Association. 2019 medical spa state of the industry: Executive summary. Available at Accessed August 6, 2019.
  2. Texas Administrative Code. Title 22. Examining Boards. Part 9. Texas Medical Board. Chapter 193. Standing Delegation Orders. Section 193.17. Nonsurgical medical cosmetic procedures.


TMLT CME on the topic