Yes, both need an exam and an order, and the reason is federal. A botulinum toxin is a prescription drug, dispensed only on the order of a licensed practitioner (21 U.S.C. § 353(b)(1)). A dermal filler is a prescription device, sold only “on the prescription or other order” of a practitioner (21 CFR § 801.109). Who may perform the exam and who may inject is state law, and few states name either product.
The toxin exam comes off the label
You do not need a vendor’s checklist to know what the examiner should ask. The Botox Cosmetic label, revised October 2024, tells you. It opens with a boxed warning: the effects of all botulinum toxin products “may spread from the area of injection to produce symptoms consistent with botulinum toxin effects,” hours to weeks later, and “swallowing and breathing difficulties can be life threatening.” The label also records that no definitive serious reports of distant spread have followed dermatologic use at the labeled doses. Both sentences belong in your consent conversation.
The contraindications are two: hypersensitivity to any botulinum toxin preparation or component, and infection at the injection site. The Medication Guide then lists what the patient should tell the examiner. Use it as the screen.
- A disease affecting muscles and nerves: ALS, myasthenia gravis, Lambert-Eaton syndrome.
- Allergy to, or a past side effect from, any botulinum toxin product.
- Breathing problems such as asthma or emphysema, or swallowing problems.
- Bleeding problems, planned surgery, or past surgery on the face.
- Weak forehead muscles or drooping eyelids.
- Any other botulinum toxin product in the last four months.
- A recent antibiotic by injection, muscle relaxants, allergy or cold medicine, sleep medicine, antiplatelets or anticoagulants.
- Pregnancy, plans for pregnancy, or breastfeeding.
On the last item, be exact. The label says there are no adequate data in pregnancy or lactation. It does not list either as a contraindication. FDA’s consumer guidance goes further and says cosmetic injection “is not recommended for use while pregnant or lactating.” State what the sources say and let the prescriber decide. Other products carry their own lines: Dysport adds allergy to cow’s milk protein.
The filler exam is about vessels and allergy
FDA’s position on filler is blunt: “Having filler injected should be considered a medical procedure, not a cosmetic treatment.” The risk it puts first is “unintentional injection into a blood vessel,” with reported complications including “necrosis (death of tissue), vision abnormalities including blindness, and stroke.” FDA recommends against injecting the glabella, the nose, the area around the eyes, the forehead or the neck, tells providers to “have an updated plan detailing how the patient will be treated should this occur,” and says not to use needle-free injection devices at all.
The device labeling supplies the history. The Juvederm and Restylane directions for use contraindicate patients with severe allergies shown by a history of anaphylaxis or multiple severe allergies, allergy to gram-positive bacterial proteins, and allergy to lidocaine. They add caution for bleeding disorders and drugs that prolong bleeding, immunosuppressive therapy, a permanent implant already at the site, a history of herpetic eruption, and a tendency to keloids or hypertrophic scarring. FDA’s page adds recent vaccination and dental work as things that can inflame an existing filler.
One correction to a claim we see often: those labels do not list autoimmune disease as a contraindication. The precaution is immunosuppressive therapy. Write the form to match the label.
Sourcing is part of the exam’s integrity
An exam that supports an order for a product you cannot trace is worth little. In April 2024 FDA reported counterfeit Botox “found in multiple states and administered to consumers for cosmetic purposes,” and stated that federal law requires providers to buy prescription drugs “only from authorized sources.” On November 5, 2025 it announced 18 warning letters to websites selling unapproved and misbranded botulinum toxin. See what “FDA approved” means.
Who examines: five answers
| State | Who performs the exam | Source |
|---|---|---|
| Maryland | The physician, personally | COMAR 10.32.09.05 |
| Washington | A physician takes the history and performs the examination | WAC 246-919-606(5) |
| Texas, Rhode Island | A physician, or a PA or APRN | 22 TAC § 169.26(c); R.I. Gen. Laws § 23-105-2(c) |
| Louisiana | A physician, or an NP in collaboration with one | LSBN Declaratory Statement (2011) |
| Arizona | A qualified licensed practitioner; telemedicine allowed for the initial exam | Board of Nursing advisory opinion (revised 2025) |
Two caveats. The Louisiana and Arizona documents are board statements, and Louisiana’s says of itself that it lacks the force of law. And California needs care. Section 2242(a) requires “an appropriate prior examination” before prescribing a dangerous drug and lets that exam be asynchronous if the standard of care is met. It speaks of drugs. A filler is a dangerous device under § 4022, so § 2242 does not by its words reach it. The exam duty for filler rests on the standard of care and on the Medical Board’s stated position that “an appropriate prior examination is required where prescriptive drugs and devices will be used, and this examination may not be delegated to registered nurses.”
Who injects, and how close the supervisor must be
Nevada is the state that names both products. Only a physician, PA, dentist, RN, APRN or podiatric physician may inject a botulinum neuromodulator, and only in a medical facility or a listed practitioner’s office (NRS 454.217). NRS 629.086 applies the same list to dermal and soft tissue fillers. LPNs, medical assistants and estheticians are absent from both.
Elsewhere the lines fall differently. Louisiana’s nursing board puts neurotoxin inside RN scope and keeps every dermal filler outside it, and requires the physician or NP on the premises; we cover that in Louisiana RNs and fillers. California’s Medical Board says “no unlicensed persons, such as medical assistants, may inject Botox.” Georgia bars delegating toxin or filler injection to medical assistants (r. 360-3-.02(21)). Texas requires the delegating physician, PA or APRN to be onsite or immediately available for emergency consultation (22 TAC § 169.26(d)).
Washington’s rule matters most for filler. If the substance is FDA approved and used on label, the physician “must be reachable by phone and able to respond within thirty minutes.” If it is unapproved or off label, “the physician must be on-site during the entire duration of the procedure” (WAC 246-919-606(12), (13)). Filler placed in the zones FDA recommends against is where that distinction bites. The full state list is in who can inject Botox by state.
Most rules never name the product
Texas covers “the injection of medication or substances for cosmetic purposes.” Washington covers injection “for cosmetic purposes” and prescription devices. Maryland covers injections “of medical products.” None says Botox or filler. Be wary of any summary that tells you a state has a “Botox law.” Texas SB 378, which would have addressed who may inject, was vetoed on June 2, 2025, and some vendor pages still describe it as law. We wrote up the veto.
What this means for you
Build the intake from the label and the FDA filler page, and keep toxin and filler as two separate screens, because they fail in different ways. Put the vascular event plan in the room where filler is injected and name who is called. Check your state’s examiner, injector and supervision rules against the sources above, and do not assume the rule that covers your neurotoxin covers your filler. Buy from authorized distributors and keep the lot number in the chart. Our service page for aesthetics and injectables sets out how we structure this, and good faith exams covers the exam itself.
Related reading
Frequently asked questions
Do you need a good faith exam for Botox?
Yes. Botulinum toxin is a prescription drug under federal law, so it may be dispensed only on the order of a licensed practitioner, and state rules require that practitioner to assess the patient first. Texas requires the relationship and record before the delegated act. Washington lists the history, examination and diagnosis a physician must complete before authorizing the procedure.
Is dermal filler a prescription product?
Yes. FDA regulates dermal fillers as medical devices and says approved fillers are indicated for prescription use only, supplied by prescription for injection by a licensed health care professional. Under 21 CFR 801.109 a prescription device is sold only on the prescription or other order of a licensed practitioner, which is why filler needs an exam and an order.
Can a good faith exam for Botox be done by telehealth?
In many states, yes, if the prescriber meets the standard of care. California allows an appropriate prior examination without a synchronous interaction for drugs. Arizona’s nursing board allows telemedicine for the initial exam. Maryland requires the physician to perform the initial assessment personally, and Connecticut requires an initial in-person assessment, so check the state.
Can a nurse inject filler without a doctor on site?
It depends on the state. Louisiana keeps dermal filler outside RN scope entirely. Washington lets a physician be reachable within thirty minutes for an approved, on-label product and requires the physician on site for off-label use. Maryland makes onsite supervision the default. Nevada limits who may inject and where.
This is general information, not legal advice. Rules vary by state and change. Confirm your own facts with counsel.