Texas Med Spa Medical Director Requirements: TMB Chapter 169

The Texas Medical Board's Chapter 169 delegation rules covered here do not use the term "medical director"; instead, they set duties for the "delegating physician" who delegates medical acts such as nonsurgical medical cosmetic procedures.^[1],[2] Those physician duties include training checks, written orders and supervision.^[3],[4],[3] Separately, the individual, business, or facility providing the delegated acts must post notices.^[5] Each Chapter 169 section in this guide was adopted effective January 9, 2025.^{[6],[2],[7],[1],[3],[4],[5]}

Does Texas law require a med spa medical director?

The rules in this guide never use the words "medical director" or "med spa."^[1],[3] They speak instead of a "delegating physician" and of "any individual, business, or facility" providing delegated acts.^[2],[5] So when people search for medical director requirements, the closest thing in these rules is the list of duties a physician takes on by delegating. Whether your business also needs a formal "medical director" title is not addressed in these sources; ask a Texas healthcare attorney.

Which med spa treatments do these rules cover?

Section 169.25 says the board determined the following to be the practice of medicine, and that these acts "can be properly delegated and supervised":^[1]

1. Nonsurgical medical cosmetic procedures, "including but not limited to the injection of medication or substances for cosmetic purposes, the administration of colonic irrigations, and the use of a prescription medical device for cosmetic purposes."^[1]
2. Using a device to administer, for human consumption, a nonprescription drug, dangerous drug, or controlled substance.^[1]

A "prescription medical device" is one the federal FDA has designated as a prescription medical device that can be sold only to persons with prescriptive authority.^[6] "Human consumption" means the injection, inhalation, ingestion, or application of a substance to or into a human body.^[6]

Common mistake: assuming §169.25 covers everything. It expressly does not include delegations "specifically authorized and described in Chapter 157 of Act," or procedures performed at a physician's practice by the physician, or by a physician assistant (PA) or advanced practice registered nurse (APRN) acting under the physician's supervision.^[1] These sources do not include the text of Chapter 157, so this guide does not describe it. For IV therapy, see our Texas IV therapy law guide on Jenifer's Law.

What must the delegating physician do before delegating?

Sections 169.26 through 169.28 sit in Subchapter E, "Other Delegated Acts," the same subchapter as §169.25.^[3],[4],[5] Sections 169.27 and 169.28 apply to acts "under this subsection," a phrase the rules do not define.^[4],[5] Read the full text with counsel to confirm which rules reach your services.

1. Have or approve a written order. A physician may delegate acts under §169.27 only after either reviewing and approving in writing the business' or facility's existing written order, or developing their own written orders.^[4]
2. Make sure the order has the required parts. It must include the identity of the delegating physician, selection criteria for screening patients, a description of appropriate care, and procedures for common complications, serious injuries, or emergencies, including communication or feedback to the delegating physician, PA or APRN.^[4]
3. Confirm your own competence. The physician must either be appropriately trained or be familiar with and able to perform the delegated act according to the standard of care.^[3]
4. Confirm the delegate's training. The delegating physician must ensure the person performing the act has appropriate training in techniques (including pre-procedural care, post-procedural care, and infectious disease control), contraindications, and recognition and acute management of potential complications.^[3]
5. Get the protocol signed. That person must sign and date a written protocol.^[3]

Chapter 169's general standards for standing delegation orders, standing medical orders and protocols also call for a signed written order, a notation of the level of supervision required unless other law specifies it, plans for patient emergencies, annual review signed by the delegating physician, and maintenance at the facility or practice site.^[2] The specific provisions in a subchapter control over those general standards.^[2]

What has to happen before each treatment?

Before the delegated act, a physician, or a PA or APRN acting under a physician's delegation, must establish a practitioner-patient relationship and complete and maintain an adequate medical record in accordance with Chapter 163.^[3],[3] They must also disclose the identity and title of the person who will perform the act, and ensure at least one person trained in basic life support is present while the patient is onsite.^[3],[3] These sources do not include Chapter 163, so this guide does not describe its record rules.

Does the physician have to be onsite at a Texas med spa?

Not necessarily. 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."^[3],[3] In addition, "if necessary, the physician must be able to conduct an emergency appointment with the patient."^[3] The rule does not define "immediately available" or set a distance or response time.

What must be posted and worn?

This duty falls on the provider, not only the physician: "any individual, business, or facility" providing delegated acts "under this subsection" must post, in each public area and treatment room, the board complaint notice required under §177.2 and the name(s) of the delegating physician(s) with their Texas medical license number.^[5] Each person performing a delegated act under that subsection must be readily identified by a name tag or similar means that clearly shows their identity and credentials.^[5]

What if the physician delegates to a PA or APRN?

If the physician delegates to a PA or APRN, the physician must register the delegate's name and license number, the start date and the practice location(s) with the board within 30 calendar days, and notify the board in writing within 30 calendar days of termination.^[7],[7]

What the rules do not address

The Chapter 169 sections in this guide do not address who may own a med spa, how many locations one physician may oversee, chart-review percentages, physician pay, or penalties for violations. Speak with a Texas healthcare attorney about those questions. See the Texas hub for more guides and our editorial policy for how we source articles.

Quick reference

Frequently asked questions

Is a medical director required for a Texas med spa?

The Chapter 169 rules covered here do not use the term "medical director" and set duties for the "delegating physician" instead.^[2],[3] Whether a separate medical director role is required is not addressed in these sources, so ask a Texas healthcare attorney.

Does a Texas med spa need written protocols?

Yes, for acts under §169.27 the physician must have reviewed and approved the business' existing written order in writing, or developed their own.^[4] The person performing the act must also sign and date a written protocol.^[3]

Who must see the patient before a cosmetic injection in Texas?

Before the delegated act, a physician, or a PA or APRN acting under a physician's delegation, must establish a practitioner-patient relationship.^[3] The rules do not define that relationship or say whether it must be formed in person or on the same day.

Does the med spa have to post the physician's name?

For delegated acts "under this subsection" of §169.28, yes: the individual, business, or facility providing those acts must post the name(s) of the delegating physician(s) and their Texas medical license number in each public area and treatment room.^[5],[5] The rule does not define which subsection that phrase means, so confirm with counsel whether it reaches your services.^[5] The complaint notice required under §177.2 must be posted there too.^[5]

What are the penalties for breaking these rules?

The Chapter 169 sections covered here do not state penalties.^[3],[5] A Texas healthcare attorney can explain what consequences may apply.