Medical spas in Maryland

Under the physicians' chapter, a cosmetic medical procedure includes subcutaneous, intradermal and intramuscular injections of medical products, and treatments meant to remove or destroy fat, when they are done to improve appearance. The chapter does not cover procedures that treat a disease.¹²

A physician must hold a Maryland licence before performing, delegating, assigning or supervising these procedures. A physician who performs, assigns, supervises or delegates them must first be trained in the indications for the procedures and how to do them. Training from a device or supply maker cannot be the only education.³ The physician must personally do the initial assessment of each patient, write a treatment plan, get the patient's informed consent to be treated by a non-physician, keep written office protocols for each procedure at each site, and remain responsible for what is delegated.⁵ Unless an exception applies, the physician must be on site whenever a non-physician performs a procedure.²⁵

The chapter lets a physician delegate a procedure to a physician assistant, or assign it to another health care provider licensed under the Health Occupations Article whose licensing board has determined that the procedure is within the provider's scope. It does not allow delegating any duty to a person who is not licensed under that Article.¹⁴¹⁹ A physician assistant may practise only after the Board has been told of an executed collaboration agreement with a physician, and a patient care team physician may not delegate to more than eight physician assistants at once outside listed settings such as hospitals.²⁰ The physicians' regulation still uses the older words: the Board may approve a delegation agreement for a physician assistant that allows "immediately available supervision", meaning direction in person, by telephone or by other electronic means, after the physician has evaluated the patient and written a treatment plan. Agreements approved before May 2009 are unaffected.²⁵ Ask the clinic which agreement covers the physician assistant who will treat you and who supervises.

The nursing chapter names neuromuscular agents, "includes, but is not limited to, Botox and Dysport", and dermal fillers as injectable treatments. A registered nurse may perform all the cosmetic procedures in the chapter's six categories. A licensed practical nurse may perform all except Category C, selective lasers.¹⁴¹⁶ A nurse must first complete a programme of study with theory and precepted clinical practice, and have documented initial and annual competency in each procedure.¹⁵ The nurse works on a prescriber's order: the authorised prescriber must assess the patient, develop the treatment plan, and be physically present in the setting and immediately available, and the informed consent must say a licensed nurse will perform the procedure.¹⁵ A nurse may not perform a cosmetic procedure on a standing order or protocol, perform the pre-procedure medical assessment, diagnose or prescribe, develop the treatment plan, prescribe medication, or perform the post-procedure medical evaluation. A nurse may not give injections for mesotherapy or lipodissolve, and may not perform Sculptra injections.¹⁶ The chapter says it does not restrict a certified registered nurse practitioner from possessing, prescribing, evaluating or performing these procedures.¹⁴ It does not define "authorized prescriber".

The Board of Dental Examiners says a dentist may use Botox and dermal fillers if the use falls within the practice of dentistry and the dentist is competent to give them.⁹ The Board of Cosmetologists lists Botox, fillers and injectables as outside an esthetician's or cosmetologist's licence.¹⁷

The physicians' chapter says a physician is on site, and the nursing chapter says the prescriber is physically present in the setting. The two do not use the same words, and the sources do not say which governs when a nurse treats under a physician's order. Ask the clinic who the prescriber is and whether that person is in the building while you are treated.

The physicians' chapter names lasers, devices that emit light or intense pulsed light, and devices that emit radio frequency, electric pulses or sound waves, when used for cosmetic purposes. Its list of procedures includes skin treatments using lasers, intense pulsed light, radio frequencies, microwave or electric pulses, and phototherapy.² The rules in the section above apply to them: the physician's licence and training, the initial assessment, the treatment plan, the consent, and on-site supervision.³⁵

Written protocols must list the equipment with the maker's specifications, operating instructions and a maintenance log; record training of everyone who uses it; set out the physician's role and the non-physician's role for each procedure; and cover common complications, emergencies, and care and follow-up afterwards.⁶

Whoever runs the device must have the training the chapter sets out. It includes theory (indications, expected outcomes, equipment, technique and infection control, complications and emergencies, charting) and clinical instruction: watching an experienced person, then doing the procedure under the delegating physician's direct supervision enough times to show competence.⁷ They must also have any training their own board requires.⁴

Under the nursing chapter, selective laser treatments are Category C. A registered nurse may perform them on a prescriber's order, with the prescriber physically present and immediately available, and a licensed practical nurse may not.¹⁴¹⁵¹⁶ Light treatments such as infrared, magenta, UVA and UVB light, and radio frequency and current treatments such as micro current, Thermage and therapeutic ultrasound, are in other categories open to both kinds of nurse.¹⁴ A nurse may not perform invasive radiofrequency procedures.¹⁶

An esthetician or cosmetologist may not do laser hair removal or IPL, radio frequency, or skin-tightening devices that heat below the epidermis.¹⁷ The statute's definition of esthetic services allows removing hair by electrical or mechanical means "other than by the use of a laser light-based device".¹⁸ The chapters have no category for a laser technician, and the physicians' chapter does not allow delegation to anyone not licensed under the Health Occupations Article.¹⁴ If you are booked for a laser or light treatment, ask who will run the device, which physician or prescriber is responsible, and whether that person will be on site.

The physicians' chapter's list of procedures includes chemical peels that ablate living skin tissue and dermabrasion, which it defines as an abrasive process to remove the epidermis and superficial dermis.² Under the nursing chapter, peels, cryotherapy and microdermabrasion are Category F. A nurse may perform Category F procedures without the prescriber being present, except cryotherapy.¹⁴¹⁶

The state's definition of esthetic services includes cleansing, exfoliating, massaging, cosmetic microneedling, stimulating and toning the skin, superficial exfoliation of the epidermis, and nonablative skin rejuvenation. It does not include diagnosis or ablation of the dermis or hypodermis.¹⁸ The Board of Cosmetologists' 2026 guidance says a limited esthetician may do dermaplaning, microneedling of 1.0 mm or less, nano-needling, superficial chemical peels limited to the epidermis, HydraFacials, LED therapy and similar surface services. It lists as outside the licence Botox, fillers and injectables, laser hair removal and IPL, radio frequency, plasma pen, HIFU, cryotherapy, medical-grade peels that go beyond the epidermis, fat dissolving, PRP and PRF, removal of skin tags, warts, moles or lesions, cosmetic tattooing and microblading, and tattoo removal. It adds that "any service that penetrates beyond the epidermis is not permissible", unless the person also holds a health occupation licence that authorises it.¹⁷ The statute lists nonablative skin rejuvenation as an esthetic service, while the guidance bars radio frequency and skin-tightening devices. Which governs a given device is a question for the Board of Cosmetologists. Ask who will do the treatment, what their licence is, and whether a physician or nurse oversees it.

No Maryland statute, rule or board statement we cite names IV hydration clinics. The physicians' chapter names subcutaneous, intradermal and intramuscular injections, not intravenous ones,² and the nursing chapter's injectable treatments are dermal fillers, micropigmentation and neuromuscular agents.¹⁴ The Board of Cosmetologists lists "IV therapy or injectable vitamins" as outside an esthetician's or cosmetologist's licence.¹⁷ Ask who ordered the drip, who evaluated you, and who will place the IV.

No Maryland board statement names semaglutide or tirzepatide. A nurse may not prescribe medication for a cosmetic procedure or work on a standing order or protocol.¹⁶ The physicians' chapter's fat-destruction wording is about procedures done with a device or product to change appearance, and it is not a rule on weight-loss drugs. Ask whether your medicine is FDA-approved or compounded, who prescribed it after examining you, and which pharmacy prepares it.

Maryland has no licence or registry for medical spas, and neither chapter uses the words "medical director". The physicians' chapter does set out what the supervising physician must do: write protocols for each procedure at each site, assess every patient personally, write the plan, obtain consent, supervise, keep records that meet state and federal privacy law, and remain responsible for what is delegated.⁵⁶ The statute lets a physician or physician assistant delegate duties to people authorised in other health occupations, to the extent the Board's rules allow.¹⁹ The sources we cite do not say who may own a med spa. That is a question for a health-care lawyer.