Medical spas in Virginia

The guidance says only three kinds of licensee may diagnose and prescribe prescription drugs, including injectable therapy: physicians, physician assistants (PAs) under a written practice agreement, and advanced practice registered nurses (APRNs) under a collaborative agreement or an autonomous practice authorisation.¹ A licensed prescriber should evaluate each patient and issue patient-specific orders, and drugs should not be given under protocols or standing orders. Nurses and unlicensed staff may not select or recommend drugs, injections or medical aesthetic procedures based only on protocols.¹

A questionnaire alone does not establish a valid relationship between practitioner and patient. If the patient has not interacted in real time with the prescriber, the guidance says, none has been established, and it notes that telemedicine can establish one.¹⁵

A nurse practitioner needs a written or electronic practice agreement with a patient care team physician, unless they have the equivalent of three years of full-time clinical experience as the Boards determine and receive an attestation.⁴

Registered nurses may give injections only on a valid order from a licensed prescriber. They may not diagnose, recommend specific compounded drugs or medical aesthetic procedures, or set the amount, route or frequency of a drug.¹² Licensed practical nurses have limited authority over injectable and IV medicines under a nursing regulation, with supervision by an RN or prescriber.¹ Medical assistants and other unlicensed staff may take a history and vital signs. They may not give injections or IV fluids, prepare or compound drugs, perform medical assessments or recommend treatment.¹ The guidance says this holds even though the Code lets a prescriber authorise trained personnel to give some controlled substances under direct supervision, by routes other than intravenous.⁶

The Code also lets a licensed practitioner delegate to supervised personnel activities that are nondiscretionary, need no professional judgment and are customarily delegated, if the practitioner assumes responsibility.² Ask who will inject you, who ordered the treatment, and whether that person has seen you.

Virginia's laser statute covers hair removal. Laser hair removal must be done by a properly trained person who is a physician, a PA or an APRN, or by a properly trained person under the direction and supervision of one of them, who may delegate it under the Code's delegation provision.³² It does not mention intense pulsed light, resurfacing or other lasers, and we found no other Virginia statute or rule on them in the sources we read.³ Virginia has no licence for the person who runs the device: the delegate is "a properly trained person". We found no training-hours rule.

The Board for Barbers and Cosmetology's 2018 guidance quotes the Code's master esthetician definition as services offered "without the use of laser technology".⁹ The hair removal statute lets a properly trained person work under a physician, PA or APRN. The sources we read do not say how the two fit for an esthetician. If you are booked for laser hair removal, ask who will run the device, how they were trained, and which physician, PA or APRN directs them.

Virginia licenses estheticians and, above them, master estheticians. The Esthetics Regulations require each licensed spa or school to make sure no licensee performs a service beyond their licence. For chemical exfoliation of the epidermis, a master esthetician may use only the listed types of exfoliant at set strengths, such as non-prescription alpha and beta hydroxy acids and a low-strength trichloroacetic acid.⁸

The Board's 2018 guidance says microneedling (needles that pierce the skin for collagen production or cell renewal) is beyond the scope of licensure and should not be done by a Board licensee. It says chemical exfoliation requires a master esthetician licence.⁹ The guidance does not say who may microneedle. If you are booking a peel or microneedling, ask who will do it, what their licence is, and who ordered it.

The guidance says all IV fluids, including plain saline, are prescription drugs. A drug may be mixed or compounded only on a valid patient-specific prescription or order. Adding vitamins or minerals makes a compounded drug, and compounding is the practice of pharmacy, regulated by the Board of Pharmacy.¹

It also says clinics that use a menu, a brief questionnaire and a basic screening by a nurse or unlicensed staff member may be operating illegally and unsafely, and that clinics with no prescriber physically present that rely on protocols or standing orders may be practising medicine without a licence, exceeding scopes of practice or compounding illegally.¹ The guidance covers fixed and mobile clinics.

The Code lets registered nurses and APRNs give intravenous infusions and injections when performed under the orders of a physician, an APRN or a PA.² Licensed practical nurses have limited IV authority. Unlicensed staff may not give IV fluids.¹ Ask who evaluated you, who ordered the drip, and who will place the IV.

The guidance names weight-loss drugs, including GLP-1 medicines, and compounded products in its scope. It says a prescriber must evaluate the patient, and that a questionnaire alone is not enough. Preparing sterile injectable products or customised formulations, such as peptides for weight loss, is compounding.¹ A medication marked "for research purposes only" is unlawful for a clinic to possess, the guidance says, whatever the patient consents to.¹

A physician may dispense drugs to their own patients after obtaining a licence and a facility permit from the Board of Pharmacy. APRNs and PAs may obtain only a limited-use licence to dispense certain Schedule VI drugs, at a non-profit facility.¹ An APRN's prescribing authority runs from Schedule II to VI, under a practice agreement unless they meet the experience and attestation rule.⁴ We found no separate Board of Pharmacy statement on semaglutide or tirzepatide. Ask whether your medicine is FDA-approved or compounded, and which pharmacy prepares it.

"Medical director" is not a defined term in Virginia's health professions title, and the guidance says applicable laws are silent on whether to designate one. Other sections of the Code restrict the term to a physician, and the guidance says it is unclear whether a med spa's medical director must be one. It describes a medical director as anyone with the legal authority to prescribe, order drugs, and supervise or delegate medical or nursing activities.¹

If a clinic uses one, the guidance says the director must remain readily available for consultation, in person or by telecommunication, and should be immediately available by phone or text in case of complications. A person with the right licence to perform the procedure and manage emergencies should always be on site during medical procedures. To stock drugs, a prescriber must practise on site at least part of the time.¹ It says nurses, dentists, chiropractors and other licensed providers may not evaluate, diagnose, decide or delegate treatment in a med spa setting.¹

On ownership, we read no Virginia rule that limits ownership of a medical practice to physicians. The Code lets professional services be rendered by a professional corporation or by an ordinary business corporation, "unless otherwise prohibited by law or regulation".⁷ The guidance says the business entity must not interfere with the clinical judgment of licensed professionals, and warns that if the medical director owns the facility, further risks may apply that it does not address.¹ Ask a health-care lawyer.

The Board for Barbers and Cosmetology's 2018 guidance says microblading with a needle or group of needles requires a tattooing or permanent cosmetic tattooing licence, and microblading with a scalpel is beyond a Board licensee's scope.⁹