Texas runs on delegation. Almost every treatment in a med spa is a medical act performed by someone other than the physician who authorized it, and the paperwork that authorizes it is the whole compliance story.
Here is how Texas delegation actually works, what has to be in writing, and where practices consistently fall short.
Texas applies the corporate practice of medicine doctrine
Start here, because it drives everything else. Texas does not generally permit a non-physician to own the entity practising medicine or to control clinical decisions. Clinical authority sits with the physician, not the owner.
This is the opposite of Florida, where non-physician ownership is broadly permitted. Content written for Florida does not transfer to Texas, and structures built for Florida frequently do not either.
The medical director requirement
A Texas med spa performing delegated medical procedures needs a medical director who is a licensed MD or DO. Under the Texas Medical Board’s rules on nonsurgical medical cosmetic procedures, that physician:
- Signs the written protocols governing the procedures performed
- Must be immediately available for consultation while procedures are performed
- Has their name and TMB license number posted in the treatment areas
An NP or PA cannot serve as medical director in Texas. They can deliver care under delegation; they cannot occupy that role.
The posting requirement is a useful diagnostic. Walk your treatment rooms. If the physician’s name and license number are not on the wall, the arrangement is probably informal in other ways too.
Written delegation, or no delegation
Texas does not recognize verbal or informal delegation. A physician who told a nurse years ago that she could inject, and never documented it, has not delegated anything.
Written delegation should be specific about:
| Element | What it has to say |
|---|---|
| Procedures | The actual named procedures — not “aesthetic services” |
| Products | The specific agents, and concentrations where relevant |
| Who | Named individuals or defined license classes, with credentials verified |
| Patient criteria | Who is a candidate, and who must be escalated |
| Supervision | What availability means in practice, and how the physician is reached |
| Adverse events | Recognition, immediate response, escalation, and reporting |
| Review | How often protocols are revisited and re-signed |
A protocol that has not been touched since your menu changed does not cover the procedures you are now performing.
Two rules that resolve most disputes
A medical director does not expand anyone’s license. Engaging a physician does not give your staff authority they never had. This is the single most common misunderstanding in the market — operators treat the medical director as a permission slip for the whole building.
Delegation cannot override scope of practice. A physician can only delegate acts the receiving license permits. If an esthetician’s license does not allow injection, no delegation makes it lawful.
Who may perform what
| License | Authority |
|---|---|
| MD / DO | Full, within clinical competency; may delegate |
| Physician assistant | Under delegation and supervision, with a prescriptive authority agreement where prescribing |
| APRN / NP | Under delegation and supervision, with a prescriptive authority agreement where prescribing |
| RN / LVN | Administration under written delegation and supervision, within scope |
| Esthetician / cosmetologist | Non-medical services only; may not inject or penetrate the dermis |
Elective IV therapy changed in 2025
If your Texas practice offers elective IV therapy outside a traditional medical setting, the law that took effect September 1, 2025 — commonly called Jenifer’s Law — is the one to read.
It limits prescribing of elective IV therapy in those settings to a PA or APRN operating under physician supervision, and limits administration to a PA, APRN, or RN under appropriate physician supervision. Prescriptive authority agreements are required, and they count against the cap on how many such agreements a supervising physician may hold.
That cap matters more than operators expect. A physician who is already at the limit cannot take on your practice, no matter what they are willing to sign.
Where Texas practices fall short
- Protocols that do not match the menu. New service added, protocol never updated.
- Stale delegation. Signed once, never reviewed, staff have turned over since.
- “Immediately available” in name only. A physician who does not answer is not available.
- Nothing posted. Name and license number missing from treatment areas.
- Assuming the director covers scope gaps. They do not.
- Supervising physician at the agreement cap. Discovered after the fact.
- Florida-style structure imported into Texas. Ownership assumptions that do not survive here.
How MDside handles Texas
We place a Texas-licensed MD or DO, write delegation and protocols against your actual service menu, keep them current as the menu changes, confirm the supervising physician has capacity under the prescriptive authority cap, and supply licensed providers to perform the evaluations.
See what is included, or read what actually changed in Texas law.
Frequently asked questions
Can an NP be a medical director in Texas?
No. Texas requires an MD or DO in that role. NPs and PAs may practise under delegation but cannot hold the position.
Does the medical director have to be on site?
The requirement is immediate availability for consultation, which is not the same as physical presence — but it does mean genuinely reachable while procedures are performed.
Can an esthetician inject if a physician delegates it?
No. Delegation cannot exceed the scope of the receiving license.
How often should protocols be updated?
Whenever the menu, products, or staff change — and on a regular review cycle regardless. Protocols that predate your current service list do not cover it.
Do I need a prescriptive authority agreement?
If a PA or APRN is prescribing, yes — and it counts toward the supervising physician’s statutory cap. Confirm capacity before you build a staffing model around a specific physician.
General information about Texas delegation and med spa regulation, not legal advice. Texas Medical Board rules and scope-of-practice requirements change. Confirm your obligations with healthcare counsel licensed in Texas.