A recent declaratory statement from the Florida Board of Nursing (DOH-24-0637) reinforces a standard that many med spas across the state may not be meeting: when a registered nurse administers aesthetic injections such as Botox, a licensed physician must be physically present and have direct visual observation of the injection.
How We Got Here
Florida’s Board of Nursing declined to issue blanket guidance on whether RNs could perform aesthetic injections. In response, a number of nurses began submitting individual petitions for declaratory statements — each describing their specific qualifications, training, and proposed supervision arrangements — and asking the Board to confirm they could inject without risk of disciplinary action.
The volume of petitions prompted the Attorney General’s office to signal that the question had been adequately addressed by prior declaratory statements and that additional petitions were unnecessary. While that message is technically debatable — declaratory statements apply only to the specific facts presented in each petition — the practical takeaway was clear: the Board is not expanding its position.
What the Declaratory Statement Says
The Cremeans declaratory statement (Final Order No. DOH-24-0637, issued May 2024) is illustrative of where the Board stands. The Board found that:
- An RN can be delegated the task of administering Botox Cosmetic by a physician licensed under Chapter 458 or 459, Florida Statutes.
- “Direct supervision” requires that the physician have visualization of the injection — meaning the physician must be physically present and watching.
- An advanced practice registered nurse (APRN/NP) cannot satisfy the supervising physician requirement. The delegation must come from, and the direct supervision must be provided by, a physician — not a nurse practitioner.
- The RN’s participation must be disclosed in the informed consent provided to the patient.
The Compliance Gap
The standard set out in these declaratory statements is unambiguous. Yet it is widely understood that the majority of med spas operating in Florida do not maintain a physician on-site during every injection. In many practices, RNs inject under APRN oversight, remote physician supervision, or with physician availability that falls short of active visualization.
That operational reality does not change the legal standard — and these declaratory statements make the risk profile of non-compliant models difficult to ignore.
Key Takeaways for Med Spa Operators and Healthcare Entities
- Physician presence is required. For RN-administered injections in Florida, direct supervision means the physician must be in the room and visually observing. Remote or standby availability does not meet the standard.
- APRNs cannot substitute for physicians in this role. Practices relying on nurse practitioners to supervise RN injectors should reassess their model.
- Informed consent must reflect RN involvement. Patient-facing documentation should clearly disclose that an RN is performing the procedure.
- Declaratory statements are fact-specific. A DS issued to another nurse does not confer protection on your practice. Each operator’s facts matter.
Entities operating in this space — whether as med spa owners, management services organizations, or affiliated physician groups — should review their supervision structures against this standard and consider whether their current models require adjustment.