Who Can Legally Perform Botox?

May 30, 2023

As the popularity of non-surgical cosmetic treatments like Botox injections continues to rise, questions about who is qualified to administer these treatments have become more common. While Botox injections are generally considered safe and effective when administered by a trained and experienced health care professional, the laws and regulations governing who can administer Botox vary widely by state and jurisdiction. Below we take a closer look at the qualifications and training required to administer Botox injections and other considerations health care professionals should be aware of when offering Botox to patients.

Any discussion about who can perform Botox must start with this foundational question: Is administering Botox the practice of medicine? Yes! Injecting Botox, and all other neurotoxins and all dermal fillers, is considered the practice of medicine in all 50 states.

What is Botox?

Botox (short for Botulinum toxin) is a purified protein produced by the bacterium Clostridium botulinum. It is a neurotoxin that works by blocking the release of acetylcholine, a neurotransmitter that stimulates muscle contractions. In medical and cosmetic applications, Botox is used as an injectable treatment to temporarily relax the muscles in specific areas of the face and neck, reducing the appearance of wrinkles and fine lines. It is commonly used to treat frown lines, crow’s feet, and forehead wrinkles. The effects of Botox usually last for several months before gradually wearing off. Botox is considered a safe and effective treatment, but it may have some side effects, such as bruising, redness, and temporary muscle weakness. Botox injections are performed by a qualified medical professional and typically take only a few minutes to administer. But prior to administering the Botox, the patient must be deemed a good candidate for the procedure by the appropriate medical professional.

What is the Practice of Medicine?

The practice of medicine refers to the activities and processes involved in the diagnosis, treatment, and prevention of diseases or injuries in humans. Medical practitioners use a range of tools, technologies, and interventions, including medication, surgery, therapy, and other medical procedures to restore, maintain, or improve the health and wellbeing of their patients. Most of the states define the practice of medicine broadly so many services that intuitively may seem non-medical do qualify as medical services. This has created confusion across the spectrum of elective and non-invasive medical services, including common services provided in medical spas, such as Botox. Many people incorrectly assume that because a service might be considered “non-invasive,” it isn’t the practice of medicine. Some states, like Texas, have enacted specific laws stating non-invasive services are in fact considered medical services. Because all states have a broad definition of the practice of medicine, it is safe to conclude that, even in states without specific laws regulating Botox, injection of Botox would be considered the practice of medicine. As a caveat, there are some states that recognize nurse practitioner independence and those states would also characterize Botox as the practice of advanced practice nursing.

What is Nurse Practitioner Independence?

Nurse practitioner independence refers to the ability of nurse practitioners to practice as primary care providers, without the need for physician oversight or supervision. This means that they can independently diagnose and treat patients, prescribe medications, and order diagnostic tests. In some states, nurse practitioners have full practice authority, while in others they may have limited autonomy or require a collaborative agreement with a physician. Because this area is developing and treated uniquely on a state by state basis, it becomes important for nurse practitioners to educate themselves on scope of practice boundaries in their state.

The Good Faith Exam

A crucial first step for any medical procedure is the good faith exam. The good faith exam, also known as an initial exam, initial consult, or medical clearance, is the first step in the patient journey where the patient receives a diagnosis and treatment plan. This is the first step in establishing the physician-patient relationship and ensures that a patient is a good candidate for the procedures they are seeking. The good faith exam must be performed by a physician, physician assistant (“PA”), or advanced practice registered nurse (“APRN”) with proper population focus and specialty. Typically, the PA or APRN must be delegated the ability to perform good faith exams by their supervising or collaborating physician. Registered nurses (“RN”) may aid the physician, PA, or APRN in administering the good faith exam, but they cannot generate orders for treatment based on the exam. A physician, PA, or APRN would need to review the RN’s findings and generate the treatment plan and order before any Botox injections are provided. But once the proper person has cleared the patient for services, who can actually administer the Botox injections?

Who Can Legally Perform Botox?

The short answer is, it depends. As mentioned earlier, the laws and regulations governing who can administer Botox vary widely by state and jurisdiction. In most states, Botox administration can be delegated by a physician to a PA, APRN, and sometimes an RN. While delegation is state specific and each state has its own nuances, there are two basic ways the laws are set up. We refer to these two constructs as the (1) dictator model and the (2) deference model.

In the dictator model, the state will specifically define who can perform medical treatments (including Botox). For example, California allows a RN, a PA, or APRN to be delegated medical treatments, including Botox. The dictator model is both clear and rigid. There is not compliant utility for using someone who does not have specific authority to be delegated treatment in a state that has the dictator model.

Other states use the deference model and place the burden on the doctor who is delegating the procedure to determine who may perform medical treatments. The doctor is held to the standard of care and puts their license on the line when deciding who they think is appropriate to provide a treatment like Botox. The doctor has discretion to delegate the procedure to anyone they feel is safe and has the appropriate level of training and experience. However, just because you are allowed to delegate, does not mean you always should.

Delegating a medical procedure to another can be an efficient way for physicians to provide care to a greater number of patients and to improve patient outcomes. However, it can also create potential legal and ethical risks for the physician. For example, if the delegated procedure is not performed correctly, the physician may be held liable for any resulting harm to the patient. Additionally, the physician may be accused of failing to provide adequate supervision or direction to the person performing the procedure. In such cases, the physician may need to defend their decision to delegate the procedure and demonstrate that they provided appropriate oversight and support. Therefore, physicians should carefully consider the risks and benefits of delegating medical procedures and take steps to ensure that the individuals they delegate to are qualified and trained to perform the procedure safely and effectively.

Delegation is just one part of the equation. Even if your state allows for these individuals to administer Botox, it is important to understand the second part of the equation: What level of supervision is required?

What is Physician Supervision?

Supervision refers to the oversight and direction provided by a licensed physician to other health care professionals who work under their authority, such as nurses, medical assistants, and other support staff. Physician supervision is an important aspect of health care delivery, as it helps to ensure that patients receive safe and appropriate care and that health care professionals are working within their scope of practice and training. It also helps mitigate the risk involved if the patient were to have an unexpected reaction to the treatment or an adverse event were to happen such as facial paralysis, a bad injection, or excessive bleeding.

The extent and nature of physician supervision may vary depending on the health care setting, the type of services being provided, and the specific requirements of state regulations. In general, physician supervision can be classified as:

  1. Direct supervision: The physician is physically present and directly supervising during the performance of certain procedures or treatments.
  2. Indirect supervision: The physician is available for consultation and direction as needed but is not physically present during the performance of procedures or treatments.
  3. General supervision: The physician provides overall direction and oversight but is not required to be physically present or available for consultation at the time of the procedure or treatment.

The level of physician supervision may be influenced by factors such as the complexity of the medical condition being treated, the potential risks involved in the procedure or treatment, and the experience and qualifications of the person performing the service. In some states the level of supervision is specified while in others it is once again left to the professional judgment of the physician.

A critical element to proper physician supervision is establishing and maintaining written treatment protocols. These protocols, also sometimes called standard operating procedures or SOPs, must be signed off by the supervising physician, or in some cases the NP or PA. This provides a step-by-step guide for the administering individual to follow and provides clarity in the procedure. The protocol also defines the standard of care and provides a layer of protection for the supervising physician as well as the providers who are performing the injections.

What if They’ve Taken a Botox Injector Course?

There are courses available which will provide training specific to the administration of Botox. Botox injector courses are designed to teach the skills and techniques necessary to administer Botox injections safely and effectively for cosmetic purposes. A typical Botox injector course may cover topics such as facial anatomy, patient selection and consultation, injection techniques, safety and risk management, and aftercare. The course may include both didactic and hands-on training, allowing participants to practice injecting Botox on live models under the supervision of experienced instructors. While the course will teach competence, taking a course does not actually give you a license to perform the procedure.

For example, if you’re a Licensed Vocational Nurse (“LVN”) in California and you’ve taken an injector training course, you still cannot administer Botox because California uses the dictator model and LVNs are not allowed to inject in California. Having a certificate that says you have the skills to perform a certain task does not provide one with the license from the state medical or nursing board. This would be different for a RN in California who completes a Botox injector course because a physician can delegate the task to a RN. So now that the RN has the skills and have received the appropriate training, the physician could delegate the administration of Botox to the RN if they felt the RN was competent and possessed the necessary skills.

ByrdAdatto Can Help

So, who can perform Botox? The answer is it depends. Almost always an APRN or a PA with proper training may perform Botox. Usually an RN with proper training may perform Botox. And sometimes in special circumstances, others if it is appropriate for them to do so and they have the proper skillset and training.

If your practice is considering administering Botox and have questions on how to do so in a compliant manner in line with your state guidelines, schedule a consult at info@byrdadatto.com.

We are grateful for the significant research and drafting contribution to this article from our Law Clerk, Clint Nuckolls. Clint is a second-year student at SMU Dedman School of Law.

ByrdAdatto founding partner Michael Byrd

Michael S. Byrd

As the son of a doctor and entrepreneur, ByrdAdatto attorney Michael S. Byrd has a personal connection to both business and medicine.