What state boards have said about cosmetic botulinum toxin and dermal filler injections

“determined the following to be the practice of medicine and such medical acts can be properly delegated and supervised: (1) nonsurgical medical cosmetic procedures, including but not limited to the injection of medication or substances for cosmetic purposes”

“A physician must either be appropriately trained or be familiar with and able to perform the delegated medical act according to the standard of care”

“A physician may delegate acts under this subsection only if the physician has either: (1) reviewed and approved in writing the business' or facility's existing written order; or (2) developed their own written orders for the delegated acts.”

“The delegating physician remains responsible for the medical acts of the person performing the delegated medical acts.”

“It is important to remember that cosmetic procedures involving medications such as Botox or Restylane will require physician delegation as will the administration of local anesthetic blocks.”

“The APRN may only accept physician delegation for those medical aspects of care and prescribing that are within the scope of the role and population focus area of APRN licensure.”

“Prior to performance of the delegated act, a physician, or a physician assistant or advanced practice registered nurse acting under the delegation of a physician, must: (1) establish a practitioner-patient relationship”

“A physician or physician assistant or advanced practice registered nurse must either: (1) be onsite during the procedure; or (2) be immediately available for emergency consultation in the event of an adverse outcome”

“procedures performed at a physician's practice by the physician or physician assistant or advanced practice registered nurse acting under the physician's supervision.”

“The practice of a physician assistant includes providing medical services delegated by a supervising physician that are within the education, training, and experience of the physician assistant.”

“Prior to performance of the delegated act, a physician, or a physician assistant or advanced practice registered nurse acting under the delegation of a physician, must: (1) establish a practitioner-patient relationship”

“A physician or physician assistant or advanced practice registered nurse must either: (1) be onsite during the procedure; or (2) be immediately available for emergency consultation in the event of an adverse outcome”

“procedures performed at a physician's practice by the physician or physician assistant or advanced practice registered nurse acting under the physician's supervision.”

“Please note, a physician, PA or APRN must either: be onsite during the procedure; or be immediately available for emergency consultation in the event of an adverse outcome”

“An RN should not perform any cosmetic procedure if he/she lacks the necessary educational preparation, knowledge, competency or skill to safely perform the procedure; lacks an appropriate order for the procedure; or lacks appropriate nursing and/or medical supervision.”

“While the Nursing Practice Act (NPA) and Board rules do not specifically address cosmetic procedures, they do prohibit RNs and LVNs from engaging in acts of medical diagnosis or the prescription of therapeutic or corrective measures.”

“the Board does not have an all-purpose list of tasks that every nurse can or cannot perform”

“The delegating physician must ensure the individual performing these medical acts: (1) has appropriate training regarding: (A) techniques for the delegated act including pre-procedural care, post-procedural care, and infectious disease control”

“Prior to performance of the delegated act, a physician, or a physician assistant or advanced practice registered nurse acting under the delegation of a physician, must: (1) establish a practitioner-patient relationship”

“A physician or physician assistant or advanced practice registered nurse must either: (1) be onsite during the procedure; or (2) be immediately available for emergency consultation in the event of an adverse outcome”

“Such medical acts can be properly delegated by a physician to individuals who have the appropriate training.”

“An LVN should not perform a cosmetic procedure if he/she lacks the necessary educational preparation, knowledge, competency, or skill to safely perform the procedure; lacks an appropriate order for the procedure; or lacks appropriate nursing and medical supervision.”

“compare an LVN who performs routine nursing tasks with an LVN who performs a delegated medical act (such as, Botox® administration). These are very different situations”

“The practice of vocational nursing must be performed under the supervision of a registered nurse, physician, physician assistant, podiatrist, or dentist.”

“Prior to performance of the delegated act, a physician, or a physician assistant or advanced practice registered nurse acting under the delegation of a physician, must: (1) establish a practitioner-patient relationship”

“A physician or physician assistant or advanced practice registered nurse must either: (1) be onsite during the procedure; or (2) be immediately available for emergency consultation in the event of an adverse outcome”

“Their use for isolated cosmetic purposes is permitted only for those dentists who have the specialty of oral and maxillofacial surgery.”

“Policy statements are not laws or rules. They are position statements developed by the Board to provide guidance on specific topics. The following policy statements reflect the Board’s current positions:”

“The performance of these procedures is the practice of medicine under RCW 18.71.011(3).”

“A physician must be fully and appropriately trained in a nonsurgical medical cosmetic procedure prior to performing the procedure or delegating the procedure.”

“Prior to authorizing a nonsurgical medical cosmetic procedure, a physician must: (a) Take a history; (b) Perform an appropriate physical examination; (c) Make an appropriate diagnosis; (d) Recommend appropriate treatment;”

“A physician who meets the above requirements may delegate a nonsurgical medical cosmetic procedure to a properly trained physician assistant, registered nurse or licensed practical nurse, provided all the following conditions are met:”

“the physician need not be on-site during the procedure, but must be reachable by phone and able to respond within thirty minutes to treat complications.”

“or that the federal Food and Drug Administration has not approved for the particular purpose for which it is used, the physician must be on-site during the entire duration of the procedure.”

“whether or not approved by the federal Food and Drug Administration for the particular purpose for which it is used, the osteopathic physician must be on-site during the procedure.”

“For a physician assistant to perform a nonsurgical medical cosmetic procedure, the physician assistant must ensure that their participating physician is in full compliance with WAC 246-919-606.”

“A physician assistant may not perform a nonsurgical cosmetic procedure unless their participating physician is fully and appropriately trained to perform that same procedure.”

“Prior to performing a nonsurgical medical cosmetic procedure, either the physician assistant or the delegating physician must: (a) Take a history; (b) Perform an appropriate physical examination;”

“The physician assistant must ensure that there is a written office protocol for performing the nonsurgical medical cosmetic procedure.”

“so long as the physician assistant's supervising physician is on-site during the entire procedure.”

“A physician assistant may not delegate the performance of a nonsurgical medical cosmetic procedure to another individual.”

“the physician need not be on-site during the procedure, but must be reachable by phone and able to respond within thirty minutes to treat complications.”

“whether or not approved by the federal Food and Drug Administration for the particular purpose for which it is used, the osteopathic physician must be on-site during the procedure.”

“The nursing laws and rules allow a competent and appropriately trained registered nurse to administer neuromodulators (such as Botox®, Dysport®, or Xeomin®). These procedures require a prescription from an authorized health care practitioner.”

“The RN may interdependently perform medical, aesthetic, or cosmetic dermatological procedures under the direction of an authorized health care practitioner (within the practitioner's scope of practice).”

“The RN or LPN cannot make a medical diagnosis, determine medical treatment, or prescribe legend drugs/controlled substances, biologics, or medical devices.”

“The physician has a written office protocol for the delegate to follow in performing the nonsurgical medical cosmetic procedure.”

“Prior to authorizing a nonsurgical medical cosmetic procedure, a physician must: (a) Take a history; (b) Perform an appropriate physical examination; (c) Make an appropriate diagnosis; (d) Recommend appropriate treatment;”

“the physician need not be on-site during the procedure, but must be reachable by phone and able to respond within thirty minutes to treat complications.”

“or that the federal Food and Drug Administration has not approved for the particular purpose for which it is used, the physician must be on-site during the entire duration of the procedure.”

“whether or not approved by the federal Food and Drug Administration for the particular purpose for which it is used, the osteopathic physician must be on-site during the procedure.”

“The LPN may perform medical, aesthetic, or cosmetic dermatological procedures under the direction and supervision of an authorized health care practitioner or RN, limited to routine nursing situations that are relatively free of complexity”

“or administering medications for sclerotherapy, asclerotherapy, or dermal fillers under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse.”

“may delegate a nonsurgical medical cosmetic procedure to a properly trained physician assistant, registered nurse or licensed practical nurse, provided all the following conditions are met:”

“Prior to authorizing a nonsurgical medical cosmetic procedure, a physician must: (a) Take a history; (b) Perform an appropriate physical examination; (c) Make an appropriate diagnosis; (d) Recommend appropriate treatment;”

“the physician need not be on-site during the procedure, but must be reachable by phone and able to respond within thirty minutes to treat complications.”

“or that the federal Food and Drug Administration has not approved for the particular purpose for which it is used, the physician must be on-site during the entire duration of the procedure.”

“whether or not approved by the federal Food and Drug Administration for the particular purpose for which it is used, the osteopathic physician must be on-site during the procedure.”

“Physicians may inject Botox, or they may direct registered nurses or physician assistants to perform the injection under their supervision. No unlicensed persons, such as medical assistants, may inject Botox.”

“The use of prescriptive drugs and devices, however, is the practice of medicine, and the same laws and regulations apply to these types of treatments as those driven by medical necessity.”

“Prescribing, dispensing, or furnishing dangerous drugs as defined in Section 4022 without an appropriate prior examination and a medical indication, constitutes unprofessional conduct.”

“they may be delegated the task of providing the appropriate prior examination and ordering the drug or prescriptive device for the patient, if acting under standardized procedures.”

“only a physician licensed by the Board - or a registered nurse, nurse practitioner, or physician assistant consistent with their practice act - may perform medical cosmetic treatments.”

“Yes, a standard NP must continue to practice under standardized procedures.”

“A 104 NP can practice without standardized procedures outside of a group setting. However, they cannot practice beyond the scope of their clinical and professional education and training, including specific areas of concentration.”

“they may direct registered nurses or physician assistants to perform the injection under their supervision.”

“The PA renders the services pursuant to a practice agreement that meets the requirements of Section 3502.3.”

“The physician and surgeon being available by telephone or other electronic communication method at the time the PA examines the patient.”

“Supervision, as defined in this subdivision, shall not be construed to require the physical presence of the physician and surgeon”

“PAs may be delegated the "appropriate prior examination" of the patient, but there are methods enumerated in the law and regulations on how physicians must provide their supervision and evaluation.”

“The Act now provides that supervision does not require the supervising physician and surgeon to be physically present, but does require adequate supervision as agreed to in the practice agreement”

“A knowledgeable and competent RN may implement a physician’s medical order for a BOTOX® Cosmetic injection upon the physician’s patient if the RN is educated and trained to a sufficient level to protect the safety of the patient.”

“Beauty salons, health spas, shopping malls, and private residences do not meet the requirement of an organized health care system for the performance of standardized procedures.”

“The law does not restrict where Botox treatments may be performed, as long as they are performed by a physician or by a registered nurse or physician assistant under a physician's supervision.”

“When functioning under "standardized procedures," physicians need not be present in the facility when the procedures are being performed. The facility, however, must be a medical setting.”

“An appropriate prior examination is required where prescriptive drugs and devices will be used, and this examination may not be delegated to registered nurses.”

“(Although the physician does not have to be onsite, he or she must be immediately reachable.)”

“patients must be examined by a physician or an advanced practitioner, such as a nurse, or a physician assistant, before treatments are administered.”

“A licensed vocational nurse may not administer Botox, Juvederm dermal fillers, or Kybella, even under physician supervision.”

“This section does not authorize a licensed vocational nurse to perform any of the following acts: (1) Administering Botox, Juvederm, Kybella, or glutathione injections.”

“Botulinum neurotoxins and Hyaluronic acid fillers, can be used by dentists as long as the procedure can be tied to one of the purposes described in Business & Professions Code Section 1625.”

“These procedures are considered the practice of medicine. Botulinum toxin is a dangerous drug and soft tissue fillers are medical device implants approved by the FDA.”

“(For a physician) Delegating the injection of botulinum toxin and/or dermal fillers to medical assistants.”

“The physician should examine/prescribe, but the physician does not have to remain on-site while the PA/APRN/RN is injecting pursuant to a written order.”

“In addition to physicians, PAs can inject toxins and fillers with a Board approved job description and Additional Duty Request, and APRNs can inject toxins and fillers with a Board approved protocol agreement and Form C.”

“The physician should examine/prescribe, but the physician does not have to remain on-site while the PA/APRN/RN is injecting pursuant to a written order.”

“if authorized by a valid individualized order prescribed by a physician, nurse practitioner (NP), or physician assistant (PA) with prescriptive authority”

“In addition to physicians, PAs can inject toxins and fillers with a Board approved job description and Additional Duty Request, and APRNs can inject toxins and fillers with a Board approved protocol agreement and Form C.”

“The physician should examine/prescribe, but the physician does not have to remain on-site while the PA/APRN/RN is injecting pursuant to a written order.”

“if authorized by a valid individualized order prescribed by a physician, nurse practitioner (NP), or physician assistant (PA) with prescriptive authority”

“if there is an individualized order/prescription and a history and physical performed by the physician, NP, or PA”

“Standing orders are not an appropriate substitute for the individualized order/prescription and history and physical”

“It is not within the RN or LPN scope of practice to make a medical diagnosis, identify medical problems, or develop medical/cosmetic/aesthetic treatment plans”

“neuromodulator and dermal filler injections (e.g., Botox, Restalyne, Collagen)”

“RNs do not have prescriptive authority, but can inject with appropriate training and a written order from a physician.”

“The physician should examine/prescribe, but the physician does not have to remain on-site while the PA/APRN/RN is injecting pursuant to a written order.”

“It is not within the scope of practice for an LPN to perform prescribed/ordered cosmetic/aesthetic procedures.”

“neuromodulator and dermal filler injections (e.g., Botox, Restalyne, Collagen)”

“for the functional or cosmetic enhancement of the gums, cheeks, jaws, lips, the oral cavity and associated tissues is a procedure which can be performed by a dentist in connection with a dental procedure in a dental treatment setting.”

“A dentist may administer an injectable pharmacologic only after having completed a Board-approved post-doctoral course that is sufficient to prepare a dentist to satisfactorily administer injectable pharmacologics safely and effectively”

“Prior to administering injectable pharmacologics to a patient, the dentist shall conduct an appropriate physical examination within the scope of dental practice, obtain a complete medical history”

“A dentist shall not delegate the administration of an injectable pharmacologic.”

“The new Board Rule will become effective on July 9, 2012.”

“The Board considers the decision to order, inject, and administer a neuromodulator, like botulinum toxin A, and dermal fillers, to be the practice of medicine.”

“I am currently board certified by an American Board of Medical Specialties or the American Osteopathic Association in plastic surgery, facial plastic surgery, or dermatology.”

“The collaborating, supervising, or covering physician must remain on-site at all times while these procedures are being performed by the APP.”

“Training may not begin until the CRNP receives written approval from the Board of Nursing and the collaborating physician receives written approval from the Board of Medical Examiners.”

“The collaborating or covering physician (MD/DO) who meets the same qualifications as the collaborating physician must be physically available on site when the procedure is performed by the CRNP.”

“The administration of botulinum toxins is prohibited in non-medical settings, including private residences and event venues.”

“Cosmetic botulinum toxin A shall be limited to FDA approved anatomical areas.”

“The Board of Medical Examiners does not authorize physicians to delegate administration of botox and dermal fillers to CRNPs.”

“Training for the PA may not begin until the PA and supervising physician receives written approval from the Board of Medical Examiners.”

“The collaborating, supervising, or covering physician must remain on-site at all times while these procedures are being performed by the APP.”

“The administration of botulinum toxins is prohibited in non-medical settings, including private residences and event venues.”

“the Board has not authorized the performance by, or delegation of this skill to, any person other than a PA or CRNP acting pursuant to a collaboration/registration agreement and the approved protocol”

“The Board considers the decision to order, inject, and administer a neuromodulator, like botulinum toxin A, and dermal fillers, to be the practice of medicine.”

“it is within the scope of practice for a registered nurse in Alabama to administer botulinum toxin A”

“the lawful prescriber must perform an in-person examination of the patient, determine the appropriateness of the treatment for the patient, and write patient-specific written orders”

“There shall be no use of “standing orders.””

“the lawful prescriber must remain at the location at which the injection is occurring.”

“a facility-specific ABN pre-approved standardized procedure on file with ABN.”

“the Board has not authorized the performance by, or delegation of this skill to, any person other than a PA or CRNP acting pursuant to a collaboration/registration agreement and the approved protocol”

“Any physician who delegates the administration of botulinum toxin to an RN or any provider other than a PA or CRNP operating under an approved protocol”

“a declaratory ruling only binds the issuing agency (in this case, the ABN) and the person requesting the ruling (the individual RN).”

“procedures involving Botox, Restylane, Collagen, and Mesotherapy are be the practice of medicine and, as such, each procedure must be performed by a licensed physician.”

“the Board has not authorized the performance by, or delegation of this skill to, any person other than a PA or CRNP acting pursuant to a collaboration/registration agreement and the approved protocol”

“to treat disease, pain, deformity, deficiency, injury, or physical condition in the area of treatment”

“The dentist shall personally perform the covered esthetic or therapeutic procedure.”

“the dentist shall establish a bona fide dentist-patient relationship with the patient, obtain an appropriate medical and dental history, perform an appropriate clinical examination, and make an appropriate record of treatment.”

““Human mouth, teeth, gums, jaws, and adjacent structures” includes the oral cavity, teeth, gingiva, cheeks, jaws, temporomandibular joint, lips, head, and neck.”

“This Rule displaces and supersedes all previous formal or informal guidance, or opinions expressed by the Board on the subject matter covered by this Rule”

“a practitioner must be actively licensed to practice dentistry, medicine, or nursing in South Carolina in order to inject neuromodulators for either cosmetic or non-cosmetic purposes.”

“it is necessary to establish a bona fide physician/practitioner relationship with the patient prior to the injection of any neuromodulator for either cosmetic or non-cosmetic purposes.”

“neuromodulators should only be injected in an appropriate clinical setting that ensures sterility and resuscitative capabilities.”

“cosmetic use is a delegable act to an appropriately qualified licensed person pursuant to state law and the physician, dentist, or APRN must be on site and readily available for any problems that may occur.”

“Non-cosmetic use is non-delegable and must be performed by either the physician or the dentist.”

“If an advanced practice registered nurse (APRN) is performing the injection, it must be done pursuant to the written practice agreement executed by and established with the collaborating physician.”

“This relationship cannot be established by an RN, but must be established by a physician, a physician assistant, or an Advanced Practice Registered Nurse (APRN).”

“cosmetic use is a delegable act to an appropriately qualified licensed person pursuant to state law and the physician, dentist, or APRN must be on site and readily available for any problems that may occur.”

“The supervising physician/APRN performs and documents an initial assessment prior to treatment and as needed during the course of therapy.”

“If a physician assistant is performing the injection, it must be done pursuant to the scope of practice executed by and established with the supervising physician.”

“This relationship cannot be established by an RN, but must be established by a physician, a physician assistant, or an Advanced Practice Registered Nurse (APRN).”

“cosmetic use is a delegable act to an appropriately qualified licensed person pursuant to state law and the physician, dentist, or APRN must be on site and readily available for any problems that may occur.”

“A registered nurse may only perform the injection for cosmetic neuromodulators with on-site supervision by a physician or APRN.”

“A Registered Nurse cannot administer botox without supervision of an APRN or physician because it is beyond the scope of practice for an RN.”

“This relationship cannot be established by an RN, but must be established by a physician, a physician assistant, or an Advanced Practice Registered Nurse (APRN).”

“The supervising physician/ Advanced Practice Registered Nurse (APRN) is immediately available on site and able to respond within five minutes to any question or adverse event.”

“The supervising physician/APRN performs and documents an initial assessment prior to treatment and as needed during the course of therapy. This practitioner/patient relationship cannot be established by an RN.”

“Dermal fillers should only be injected in an appropriate clinical setting that ensures sterility and resuscitative capabilities.”

“these are limited to the perioral area, must be for a dental purpose, must be performed by a licensed general dentist, and must be performed only where a bona fide dentist-patient relationship has been established.”

“a practitioner must be actively licensed to practice dentistry, medicine, or nursing in South Carolina in order to inject neuromodulators for either cosmetic or non-cosmetic purposes.”

“The performance of cosmetic procedures, such as the injection of botulinum toxin, dermal fillers, permanent makeup at a location that is not licensed under the rules in Chapter 3701-9 of the Administrative Code”

“When a physician delegates the administration of drugs, that physician shall provide on-site supervision, except in the following situations:”

“"On-site supervision" means that the physical presence of the physician is required in the same location (e.g., the physician's office suite) as the unlicensed person to whom the medical task has been delegated”

“Prior to a physician's delegation of the performance of a medical task, that physician shall determine each of the following: (1) That the task is within that physician's authority; (2) That the task is indicated for the patient;”

“failed to provide proper on-site direction and supervision when she delegated the administration of injections of botulinum toxin to a registered nurse without ever being physically present at the clinic”

“The individual will be considered an unlicensed person for purposes of completion of the delegated task and the physician must meet all the requirements in Section 4731.053 and the rules under Chapter 4731-23.”

“may practice only in accordance with a standard care arrangement entered into with each physician or podiatrist with whom the nurse collaborates.”

“A certified nurse practitioner may, in collaboration with one or more physicians or podiatrists, prescribe drugs and therapeutic devices in accordance with section 4723.481 of the Revised Code.”

“The Board does not maintain a list of procedures that a particular APRN may or may not perform.”

“Prior to delegating the authority, the nurse shall do both of the following: (1) Assess the patient and determine that the drug is appropriate for the patient;”

“The advanced practice registered nurse is physically present at the location where the drug is administered.”

“may perform any of the following services authorized by the supervising physician that are part of the supervising physician's normal course of practice and expertise:”

“The supervising physician shall be continuously available for direct communication with the physician assistant by either of the following means: (a) Being physically present at the location where the physician assistant is practicing;”

“being in a location that is a distance from the location where the physician assistant is practicing that reasonably allows the physician to assure proper care of patients”

“A supervising physician shall not authorize a physician assistant to perform any service that is beyond the physician's or the physician assistant's normal course of practice and expertise.”

“The physician assistant must be physically present at the location where the task is performed or the drug administered.”

“The scope of practice for licensed nurses may include the administration of cosmetic/aesthetic injectable medications, in circumstances where:”

“The nurse may execute the cosmetic/aesthetic injectable medication regimen with a valid authorized provider order.”

“Administering medications, treatments, and executing regimens authorized by an individual who is authorized to practice in this state and is acting within the course of the individual's professional practice;”

“failed to provide proper on-site direction and supervision when she delegated the administration of injections of botulinum toxin to a registered nurse without ever being physically present at the clinic”

“The individual will be considered an unlicensed person for purposes of completion of the delegated task and the physician must meet all the requirements in Section 4731.053 and the rules under Chapter 4731-23.”

“Guidelines for licensed nurse administration of cosmetic/aesthetic injectable medications (Sections 4723.01(B) & (F), Ohio Revised Code (ORC)):”

“a registered nurse or a licensed practical nurse”

“at the direction of a registered nurse or any of the following who is authorized to practice in this state: a physician, physician assistant, dentist, podiatrist, optometrist, or chiropractor.”

“the nurse has a specific current valid order or direction from an individual who is authorized to practice in this state and is acting within the course of the individual's professional practice;”

“failed to provide proper on-site direction and supervision when she delegated the administration of injections of botulinum toxin to a registered nurse without ever being physically present at the clinic”