The Good Faith Exam Is Not One Rule: What Eight States Actually Require

We read the primary source documents for eight states on 19 August 2026. Not one uses the phrase "good faith exam". California's rule is about prescribing dangerous drugs. Texas says "establish a practitioner-patient relationship". Washington says "perform an appropriate physical examination". The industry's term of art is not a legal term in any of the eight.

That matters more than it sounds. The phrase implies one requirement with one shape, so a protocol written for a Texas clinic gets copied into a Nevada clinic and quietly fails. The documents disagree on format, on who performs the exam, on whether each session needs its own order, on where the physician has to be standing, and on whether they bind anyone at all.

This post prints what each source says, with its section number and date, and separates the four states where the requirement sits in statute or rule from the four where it rests on board documents.

Every source on this page was read on 19 August 2026. We make med spa software, so we have an obvious interest in clinics recording exams and orders inside a system. The citations below hold regardless of whose software you run them in, and none of this is legal advice.

The phrase is an industry term, not a code term

Read what the code says instead. In Texas, 22 Texas Administrative Code 169.26(c), adopted effective January 9, 2025 and published at 50 TexReg 342, requires that before a delegated act a physician, PA or APRN acting under delegation "must: (1) establish a practitioner-patient relationship; (2) complete and maintain an adequate medical record in accordance with Chapter 163 of this title; (3) disclose the identity and title of the individual who will perform the delegated act; and (4) ensure at least one person trained in basic life support is present while the patient is onsite."

The phrase "good faith exam" appears in none of 169.25, 169.26, 169.27 or 169.28. The Texas Medical Board uses a close cousin, but in enforcement rather than in rule: its newsroom item on the June 2024 meeting describes agreed cease and desist orders entered on 21 June 2024 finding a failure "to ensure a good faith evaluation was performed by the medical director or any qualifying physician, physician assistant or nurse practitioner prior to performing or offering to perform non-surgical cosmetic procedures". Evaluation, not exam, and in an enforcement document rather than in the rule.

Point four of 169.26(c) is a staffing rule hiding inside a clinical rule. Someone trained in basic life support has to be present the whole time the patient is on site. That is a rota problem, not a chart problem.

Eight states, eight kinds of document

The table shows which document carries the pre-treatment requirement in each state we checked, what kind of document it is, and its date. The middle column is the important one.

Four of the eight carry text you can be cited under directly: the California statute, the Texas rules, the Washington rule and the Florida telehealth statute. Florida's declaratory statements on injectables sit beside that statute and bind only their petitioners. Nevada, Arizona and Oklahoma rest on nursing board practice documents. Oklahoma's medical board document disclaims enforceability on its face. Georgia's is a position statement about IV therapy and supervisory relationships, not med spa examinations.

That does not make board documents ignorable. A practice decision is how a board reads its own practice act, and it is the lens applied when a nurse's licence is at issue. It is still a different animal from a regulation, and a binder citing all eight as equivalent authority is misdescribing its own risk. One boundary on this research: every requirement we located is state law or state board guidance, and we examined no federal source.

California and Florida put the exam format in a statute

California's rule is the most misquoted, because it is not framed as a med spa rule. Cal. Bus. and Prof. Code 2242(a) opens: "Prescribing, dispensing, or furnishing dangerous drugs as defined in Section 4022 without an appropriate prior examination and a medical indication, constitutes unprofessional conduct." It defines misconduct by the prescriber, and reaches neuromodulators and fillers because those are dangerous drugs requiring a prescription, not because the section names aesthetics.

Then comes the sentence the telehealth aesthetics model rests on: "An appropriate prior examination does not require a synchronous interaction between the patient and the licensee and can be achieved through the use of telehealth, including, but not limited to, a self-screening tool or a questionnaire, provided that the licensee complies with the appropriate standard of care." The section was amended by Stats. 2019, Ch. 741, Sec. 1 (AB 1264), effective 11 October 2019.

The closing proviso is load-bearing and gets dropped constantly. A questionnaire is expressly permitted as a vehicle, and only where the licensee still meets the standard of care. The statute settles format and leaves adequacy exactly where it was.

Florida reaches a similar place by another route. Fla. Stat. 456.47(2)(b) provides that "A telehealth provider may use telehealth to perform a patient evaluation", and that a provider conducting an evaluation "sufficient to diagnose and treat the patient" is "not required to research a patient's medical history or conduct a physical examination of the patient" first. Subsection (2)(a) holds the provider to "the prevailing professional standard of practice for a health care professional who provides in-person health care services", and the definition in (1)(a) covers synchronous or asynchronous technology while expressly excluding "e-mail messages or facsimile transmissions".

One dating fact, because the page gets cited as current policy: the Medical Board of California's med spa resource page is a reprint of an article closing with the line "Newsletter, January 2007, Page 10". Read on 19 August 2026, it carries no code citations and never uses the word "examination". We located no California authority stating who may perform the prior examination.

Texas: the chapter moved in 2025, and the written order has four parts

The Texas rules for delegated cosmetic procedures were renumbered. The Texas Medical Board's Rule Review Reorganization matrix maps new Chapter 169, "Physician Delegation and Supervision", to old chapters 193 and 197. That published mapping is chapter level, so the defensible statement is that Chapter 193 is gone, not that a specific old section became a specific new one. The 22 TAC 193.17 citation is still widely used in published guidance.

Subchapter E contains four rules: 169.25 Other Delegation, 169.26 General Standards, 169.27 Physician Responsibilities Related to Written Order, 169.28 Notice and Identification Provisions. There is no 169.29. Guidance citing a range ending at 169.29 was not read off the Secretary of State's viewer, which is a fast way to spot a stale summary.

22 TAC 169.25(a) determines to be the practice of medicine "nonsurgical medical cosmetic procedures, including but not limited to the injection of medication or substances for cosmetic purposes... and the use of a prescription medical device for cosmetic purposes".

Then 169.27 does the part most compliance content gets backwards. Subsection (a): "A physician may delegate acts under this subsection only if the physician has either: (1) reviewed and approved in writing the business' or facility's existing written order; or (2) developed their own written orders for the delegated acts." The physician need not author the order. Approving the clinic's existing order in writing satisfies the rule, which makes that written approval an artifact you have to produce, dated and signed.

Two Texas facts that circulate wrongly. Senate Bill 378 of the 89th Legislature Regular Session, captioned "Relating to certain prohibited practices by a barber or cosmetologist", was vetoed by the Governor on 2 June 2025 and is not law. The 2025 Texas bill in this space that did take effect is HB 3749, "Relating to the regulation of the provision of elective intravenous therapy", effective 1 September 2025. And the Texas Medical Board's FAQ 313 states: "There is currently no registration for Med Spa clinics in Texas."

Washington: one rule that does the whole job

Washington is the counterexample to the idea that this obligation is always stitched together from separate statutes. WAC 246-919-606 carries the examination duty, the delegation conditions, the protocol contents and the presence rules in one regulation, filed as WSR 20-22-003 and effective 21 November 2020.

Subsection (5): "Prior to authorizing a nonsurgical medical cosmetic procedure, a physician must: (a) Take a history; (b) Perform an appropriate physical examination; (c) Make an appropriate diagnosis; (d) Recommend appropriate treatment; (e) Obtain the patient's informed consent; (f) Provide instructions for emergency and follow-up care; and (g) Prepare an appropriate medical record." The duty is placed on "a physician" and the rule does not write it as delegable. Subsection (16) closes the other end: "A physician may not permit a delegate to further delegate the performance of a nonsurgical medical cosmetic procedure to another individual."

The scope carve-out is what most Washington summaries miss. Subsection (2) excludes surgery, prescription lasers, noncoherent light, intense pulsed light, radiofrequency, plasma applied to the skin, nonprescription devices and intravenous therapy. Lasers and light are covered by WAC 246-919-605 and 246-918-125 instead. If half your menu is energy-based, this is not the rule for that half. The section also sits in the chapter governing medical practice, and we verified no osteopathic parallel.

The useful convergence is between Texas and Washington on what the written order or protocol must contain.

Two states, near-identical wording. If you operate in both, one document drafted to the Washington list satisfies the Texas list on content, with the Texas posting duties under 169.28 handled separately.

Washington adds one thing Texas does not. The delegate's decision criteria and the method for documenting decisions have to be written down. That is a workflow specification, not a policy statement: it describes what the person in the room may decide without calling anyone. For groups running more than one site, the failure mode is protocol drift, where one clinic's binder gets updated and the others do not. Whatever system holds your protocols needs a single current version per state with a visible approval date, the same discipline multi-location med spa software has to impose on pricing and permissions.

Nevada and Arizona: board grids, and a word that inverts

Nevada's operative document is the Nevada State Board of Nursing Practice Advisory Decision on scope of practice for RNs and LPNs performing aesthetic and cosmetologic procedures, Board Approved 17 January 2025. It is a practice decision interpreting NRS and NAC, not a regulation. The board's practice decisions page lists it as current and separately lists an older item, "Cosmetic Procedures", as rescinded in March 2012.

Section II.H is the sentence that changes scheduling: "An order for each individual intervention by a qualified licensed practitioner that has assessed the patient and established a bonafide patient/provider relationship in compliance with NRS 639.235.4." Section II.I adds that the nurse "can remove and possess only the specific solutions/medications that have been ordered for the patient".

The supervision letters invert what most readers assume. The legend reads: "N = No Supervision Required; D = Provider is available for Direct supervision (Provider is available for consultation NRS 644A.545); I = Provider is available for Immediate supervision". NAC 632.048 defines direct supervision as direction from a supervisor "who is periodically available at the site where care is provided to a patient or available for immediate guidance". NAC 632.059 defines immediate supervision as direction from a supervisor "who is physically present at the site where care is provided to a patient and directly observing or assisting in that care". In Nevada, Direct is the looser standard and Immediate means in the room, watching.

The grid is organised by procedure rather than by injection site, with one exception. Tissue and dermal fillers excluding the under eye, nasal, jawline and temporal zones sit at RN with D. Filler to those four zones steps up to RN with I. LPN is marked Not Within Scope for both. Four anatomic zones are the only place where the same product changes the supervision answer.

Arizona's document is the State Board of Nursing Advisory Opinion on medical aesthetic procedures, approved 26 July 2011 and revised 1/13, 1/15, 03/19 and 1/2025. Paragraph D says an initial face to face examination "should be performed", which is permissive, then contains a sentence that stops mid-clause in the board's own published PDF: "Telemedicine may be used for the initial exam provided it is performed". The provisos are not in the document and we are not going to guess them. Paragraph H limits the order requirement to Level II and Level III procedures, and Level I expressly does not require an LP order. In the Level III table, neuromodulators and fillers are marked only in the RN and APRN columns. Arizona also expressly contemplates an APRN serving as medical director consistent with R4-19-101. The live board URL returned 403 to every automated fetch attempted on 19 August 2026, and the content was read from an Internet Archive capture of the same URL dated 31 March 2025, so open the board's own copy before relying on paragraph D.

Standing orders: nursing boards are copying each other across state lines

The Oklahoma Board of Nursing's Cosmetic/Aesthetic Dermatological Procedures Guidelines, OBN Policy/Guideline #P-25, Board Approved 24 March 2026 and Board Revised 19 May 2026, states three times in bold, at sections II, III and V.C: "Standing orders are not an appropriate substitute for the individualized order/prescription and history and physical." Its cited authority is 59 O.S. 567.3a(2), (3), (4) and (5), the nursing practice act. That is the Board of Nursing speaking, in a policy guideline. The Oklahoma State Board of Medical Licensure and Supervision's med spa guidelines, approved 18 January 2024 and read in full on 19 August 2026, say nothing about standing orders and carry the express disclaimer that they "are not enforceable as a rule or law".

It would be tidy to call this an Oklahoma outlier. It is not. The identical sentence appears in the Georgia Board of Nursing's IV hydration position statement, quoted verbatim inside the Georgia Composite Medical Board's IV Hydration/Therapy Position Statement dated 7 May 2026. Oklahoma's own reference list cites the Georgia Board of Nursing Cosmetic/Aesthetic Procedures Position Statement of 1 April 2024 and the North Carolina Board of Nursing Cosmetic/Aesthetic Dermatological Procedures Position Statement of February 2024 as sources.

That is the finding worth carrying. Nursing boards are borrowing each other's wording on standing orders, so the same sentence propagates across state lines without any legislature acting. The medical board documents we read did not converge the same way. If your model rests on a standing order, the exposure sits on the nurse's licence first, under language drafted somewhere else. Oklahoma cuts the other way on presence: OBN P-25 states that the RN's performance of these procedures "does not require the on-site presence of a physician, APRN, Physician Assistant (PA), or other licensed health care practitioner" where there is a valid individualized order and a completed history and physical. Both Oklahoma documents permit the initial evaluation to be "either face to face or via telemedicine", the medical board's citing OAC 435:10-1-4.

Georgia's May 2026 statement is worth reading for a separate reason, though it is an IV therapy document rather than a med spa or examination document. It says the Board evaluates physician and APRN arrangements "based upon the substance and practical effect of the relationship rather than solely upon the formal structure, title, or contractual characterization", and reads "employee" in O.C.G.A. 43-34-25(n) to cover a physician receiving "compensation of any kind, monetary or non-monetary" from an APRN or an APRN-owned company in exchange for supervising. Its verbs are hedged throughout, the trigger it describes is the APRN paying, and a physician-owned practice paying a staffing firm is not addressed.

Where the physician has to be

This is where the documents diverge hardest. The table gives each presence standard in its own words.

Read the two Washington rows together. The trigger is not the procedure, it is the regulatory status of what is in the syringe for the purpose it is used for. A great deal of aesthetic injecting is off-label by design, and under 246-919-606(12) that puts the physician in the building for the entire procedure. The thirty minutes in (13) is a response time to treat complications while reachable by phone, not a permission to be a thirty-minute drive away.

The Florida row is the strictest standard in the set and the narrowest in application. DOH-24-0640-DS-MQA is a declaratory statement under s. 120.565, Florida Statutes, and it says on its face that the Board's answer applies "under the specific facts of the petition". It binds its petitioner and is not general Florida law. What it does tell you is how that Board read the words in 2024, which matters when you are drafting supervision language of your own.

Nevada's periocular filler row is the one that changes the schedule. Tear trough filler puts the provider in the room and observing, a different appointment shape and a different cost than the same product in the cheek. That distinction has to survive into your booking rules, not just the protocol binder.

How to check your own clinic in an afternoon

Open the primary document for your state, not a summary. For California that is leginfo, for Texas the Secretary of State's Texas Administrative Code viewer at Title 22, Part 9, Chapter 169, Subchapter E, for Washington the WAC page, and for Nevada, Arizona and Oklahoma the board's own PDF. If the page you are reading cites 22 TAC 193.17, or a range ending at 169.29, it predates the current Texas rules.

Then pull the artifacts the documents name. From Texas: the written order or the physician's written approval of the facility's existing one; the record under 22 TAC Chapter 163 and disclosure of who performed the act; and under 169.28, the complaint notice under 22 TAC 177.2 and the delegating physicians' names with Texas licence numbers, posted in each public area and treatment room, plus name tags. From Washington: the physician's training record, the quality assurance programme, the written office protocol, the signed consent naming the delegate and their licence, and the delegate name tag. From Nevada: the individualized order per intervention, retained informed consent, and documentation of instructional programme completion and supervised practice held by the employer, which Arizona's paragraph G also requires.

Then answer six questions in writing with a citation beside each. Who performed the pre-treatment evaluation for the last ten charts, and does your state's document permit that person to perform it. Was the evaluation synchronous, and does your state care. Is there an order tied to the specific session, or one order covering a series. Where was the supervising clinician during each of those ten treatments. Does your written order or protocol contain the four elements. Is there a dated signature on it from the delegating physician, whether authored or approved.

Where an answer is uncomfortable, the fix is usually structural rather than clinical. An order per session is a scheduling artifact: it has to be created when the appointment is created and refuse to be reused. A protocol with a review date needs an owner and a reminder. A supervision level that changes by treatment zone has to be attached to the service, so the calendar requires the right provider before anyone books. Whatever booking software you run, that logic belongs in the booking rules, because that is the only place it gets applied every time rather than remembered most of the time. Where the clinical record itself lives is a related question, and we have written about where an EMR ends and practice software begins.

Then take the six answers to a healthcare attorney licensed in your state. Everything above is a reading of public documents with the section numbers printed so you can check us. Board documents in particular are interpretations, and they can be revised at any meeting.

Frequently asked questions

Can a good faith exam be done over telehealth?

It depends on the state, and the phrase appears in none of the eight state documents we read on 19 August 2026. California Business and Professions Code 2242(a) says an appropriate prior examination "does not require a synchronous interaction between the patient and the licensee and can be achieved through the use of telehealth, including, but not limited to, a self-screening tool or a questionnaire, provided that the licensee complies with the appropriate standard of care." Florida Statutes 456.47(2)(b) permits a telehealth patient evaluation, and Oklahoma's board documents permit an initial evaluation "either face to face or via telemedicine".

Can a registered nurse perform the good faith exam?

The documents mostly answer a different question, which is who may perform the procedure. Washington places the pre-authorisation duty in WAC 246-919-606(5) on "a physician" and does not write it as delegable. Texas 22 TAC 169.26(c) allows a physician, or a physician assistant or advanced practice registered nurse acting under delegation, to establish the practitioner-patient relationship. Nevada's Board of Nursing requires an order from "a qualified licensed practitioner that has assessed the patient". We located no California authority stating who may perform the prior examination.

Does every session in a series need its own order?

In Nevada, the Board of Nursing's Practice Advisory Decision approved 17 January 2025 requires "an order for each individual intervention by a qualified licensed practitioner that has assessed the patient and established a bonafide patient/provider relationship in compliance with NRS 639.235.4." That is a per-intervention requirement, not a per-course one, and it comes from a board practice document rather than a regulation. Oklahoma's Board of Nursing requires an individualized order and a completed history and physical, and says standing orders are not an appropriate substitute for them.

Is a standing order enough for injectables?

Several nursing boards say no, in identical words. The Oklahoma Board of Nursing's Policy/Guideline #P-25, revised 19 May 2026, states three times: "Standing orders are not an appropriate substitute for the individualized order/prescription and history and physical." The same sentence appears in the Georgia Board of Nursing's IV hydration position statement, quoted inside the Georgia Composite Medical Board's statement of 7 May 2026, and Oklahoma cites Georgia and North Carolina board statements as its sources. These are board practice documents rather than regulations, and they bear on the nurse's licence.

Does the physician have to be on site during the treatment?

It varies by state and, in Washington, by what is in the syringe. WAC 246-919-606(12) requires the physician on site for the entire procedure where the substance is not FDA approved for the purpose used. Subsection (13) allows off-site presence for on-label use if the physician is "reachable by phone and able to respond within thirty minutes to treat complications". Texas 22 TAC 169.26(d) allows onsite presence or immediate availability for emergency consultation. Nevada steps up to physically present and directly observing for filler in four facial zones.

What has to be in a written order or protocol?

Texas 22 TAC 169.27(b), effective 9 January 2025, requires four things: the identity of the delegating physician responsible for the delegation, selection criteria for screening patients, a description of appropriate care, and procedures for common complications, serious injuries or emergencies including feedback to the delegating physician, PA or APRN. Washington's WAC 246-919-606(11)(d) requires a near-identical list and adds the activities, decision criteria and plan the delegate must follow, with a method for documenting decisions.

What changed in the Texas med spa rules in 2025?

Chapter 169, Subchapter E of Title 22 of the Texas Administrative Code was adopted effective 9 January 2025, published at 50 TexReg 342. It holds four rules: 169.25 Other Delegation, 169.26 General Standards, 169.27 Physician Responsibilities Related to Written Order, and 169.28 Notice and Identification Provisions. There is no 169.29. The Texas Medical Board's Rule Review Reorganization matrix maps new Chapter 169 to old chapters 193 and 197, so citations to 22 TAC 193.17 point to a chapter that no longer appears in the Secretary of State's Part 9 chapter list, read on 19 August 2026.

Does a Texas physician have to write the order personally?

No. 22 TAC 169.27(a) provides that a physician may delegate "only if the physician has either: (1) reviewed and approved in writing the business' or facility's existing written order; or (2) developed their own written orders for the delegated acts." Approving the facility's existing order in writing satisfies the rule. That makes the written approval itself something you have to be able to produce, with a date and a signature, alongside the order it approves.