Medical spas in Washington

Physicians may inject. PAs work under a collaboration agreement, and a PA with fewer than 4,000 postgraduate clinical hours must work under a participating physician's supervision. For a PA to perform a cosmetic procedure, the PA must make sure the participating physician follows the cosmetic rule and is trained in the same procedure.⁶ Advanced registered nurse practitioners have independent prescriptive authority.⁷

The Board of Nursing says a competent, trained RN may administer neuromodulators, and a competent LPN may administer neuromodulators and fillers, on a prescription from an authorized health care practitioner, and that the nursing laws do not require a practitioner on the premises. It adds that the physician's cosmetic rule still applies.⁸⁹ The Board's 2025 opinion says an RN or LPN cannot make a medical diagnosis, determine treatment or prescribe.¹⁰

A certified medical assistant may give injections under supervision.¹³ Whether that includes a cosmetic injection is not settled by the sources we read, because the cosmetic rule lists PAs, RNs and LPNs as delegates and no Washington text names cosmetic injectables for medical assistants.

Dentists: the Dental Commission withdrew its 2013 statement on botulinum toxin and fillers in January 2020, saying dental schools now teach neurotoxin injections. The Board of Nursing's FAQs still say a dentist may use them to treat functional esthetic dental conditions and their direct esthetic consequences.⁸¹¹ Naturopathic physicians may give injections as minor office procedures.¹²

Ask who will inject you, what their licence is, and which physician is responsible for them.

Use of a laser, noncoherent light, intense pulsed light, radiofrequency or plasma device that is an FDA prescription device and penetrates skin is the practice of medicine.³ We found no laser operator licence, certificate or facility registration.

The Department of Licensing says laser technicians can get a master esthetics licence or a Department of Health licence that allows a medical prescriptive device. The page does not say which Health licence it means.¹⁵ Estheticians and master estheticians may use medical devices the FDA has approved as over-the-counter.¹⁵

The esthetics law covers care of the skin with exfoliants, superficial and light peels, and any device except laser. It says esthetics never includes injections. Master esthetics adds medium depth peels and the use of medical devices for skin care and permanent hair reduction, and says use of a medical device must comply with any law that requires delegation or supervision by a licensed health professional.¹⁴

The sources do not agree on who may use a prescription device. The Departments of Health and Licensing say an esthetician may use a laser or other prescription device only under the supervision of an MD or DO.¹ The Department of Licensing's licence page says master estheticians may use FDA prescriptive devices only under a physician's authority.¹⁵ The law itself puts lasers in master esthetics.¹⁴ Microneedling is not named in the esthetics law.

The cosmetic rule does not cover intravenous therapy.⁴ The Department of Health says anyone who administers medication, for example in a med spa, must have legal authority to do so. An IV hydration bag is a medication, so a medication order is required before IV hydration therapy begins.¹ Ask who will examine you before the drip, who ordered it, and who will place the IV. We found no Washington mobile IV rule.

Washington's Pharmacy Commission approved a statement on compounded semaglutide in August 2024. It says compounding must not copy a commercially available drug regularly or in inordinate amounts, no salt form of semaglutide may be used in a compounded drug product, and the ingredient must be pharmaceutical grade, not "research use only", and from an FDA-registered establishment licensed in Washington. It warns of disciplinary or enforcement action by the Commission or the FDA.¹⁹ The statement speaks of the 2024 FDA shortage listing. We found nothing naming tirzepatide in Washington sources. Pharmacies and others who compound must follow the national compounding standards.²⁰

A health care entity that buys, administers, dispenses and delivers legend drugs must be licensed by the Department of Health. The definition excludes an individual practitioner's office or a multipractitioner clinic unless the owner elects licensure. Whether a given med spa falls under that exclusion is a question for a lawyer.¹⁸

No Washington statute or rule we read requires a medical director for a med spa. The Medical Commission has a guideline on what a medical director should do, including making sure each clinical staff member is licensed, trained and acting within scope. The Commission says a guideline does not have the force of law.¹⁶

We found no express Washington statute on the corporate practice of medicine. The state's guidance page lists restrictions on who can own a business and prohibitions against fee-splitting and the corporate practice of medicine, and tells readers to see an attorney.¹ A professional service corporation may be organised by individuals licensed to render the same professional service, and PAs may own their own practice or clinic.⁶¹⁷ A 2025-26 bill to codify the doctrine, SB 5387, had not passed when we read it.²³

Unlicensed practice is a gross misdemeanour, and the Secretary of Health may fine up to $1,000 a day.²⁷

For cosmetic procedures, a physician must take a history, perform a physical examination, make a diagnosis, recommend treatment, get informed consent, give emergency and follow-up instructions and keep a record before authorising a nonsurgical medical cosmetic procedure.⁴ The laser rule has the same steps.³

A physician may delegate a cosmetic procedure to a properly trained physician assistant (PA), registered nurse (RN) or licensed practical nurse (LPN) if there is no surgery, the work is within the delegate's scope, the delegate is trained, and a written office protocol is followed. Each patient signs a consent form that lists foreseeable side effects and complications, and the identity and licence of the person treating them. If the medication or substance is not FDA-approved for that use, the physician must be on site during the whole procedure. If it is approved for that use, the physician need not be on site but must be reachable by phone and able to respond within thirty minutes to treat complications. A delegate may not delegate further.⁴

Laser delegation has its own conditions. The delegate must be properly trained and licensed in a profession whose scope allows these devices, and the delegating physician must be on the immediate premises during the patient's initial treatment.³

The Department of Licensing licenses tattoo artists, body art artists, body piercers and permanent cosmetics artists.²¹²² The body art law does not use the words "permanent cosmetics", and it excludes health-related procedures done by licensed health care practitioners under their scope of practice.²¹