Who is allowed to inject you in Québec

“Practising in the field of aesthetic medicine is first and before anything else practising medicine.” That sentence belongs to the Collège des médecins du Québec, from its 2020 practice guide, and it is the part most advertising for injectables leaves out. Botulinum toxin and dermal fillers are not beauty services that happen to involve a needle. They are medical treatments, and Québec sets rules about who may plan them, who may administer them, and where.

The evaluation comes before the product

The Collège's position is that any patient who wants injections for aesthetic purposes must first undergo a medical evaluation, so that the physician can establish an individualized treatment plan. Not a conversation about which package to buy — an examination that produces a diagnosis and a plan. The guide is explicit that a physician must not write a prescription for an aesthetic treatment without having gone through those steps with rigour and competence.

And it has to be in person

This is the requirement people are most often surprised by. The Collège states that the physician must evaluate the patient in person, and that a remote evaluation by telemedicine does not meet the requirements of adequate and safe practice for this type of treatment. A form, a photograph and a video call are not an evaluation.

Who may hold the syringe

Two arrangements are permitted. The treatment may be carried out by the physician who performed the evaluation. Or it may be carried out by a nurse or an auxiliary nurse, executing an individual prescription issued by that same physician.

The second arrangement carries conditions, and they are worth knowing as a patient. The treatment must take place in premises meeting the regulatory requirements that apply to out-of-hospital care settings. A physician must be accessible and available on site to take charge of an adverse reaction if one occurs. And the nurse cannot modify the content of the prescription without a new evaluation of the patient by the physician.

The collective prescription is gone

There used to be a workaround. A physician would sign a collective prescription, and injections would be given under it by people that physician had never examined anyone for. The Collège moved to end this: that physicians no longer be authorized to issue a collective prescription for aesthetic injections, nor to permit the execution of one issued previously. If somewhere offers to inject you on the strength of a standing order from a doctor you will never meet, that is the arrangement that was discontinued.

Where it may happen

The guide gives its own example, and it is blunt: a medical consultation and the treatments that follow from it cannot take place in a hair or beauty salon, in the middle of the clients and the hairdressers or beauticians. The setting has to meet the standards that apply to the practice of medicine — the consulting room itself, asepsis and infection prevention, a medical record, and the confidentiality of what you tell the physician.

The product in the syringe

Those rules govern the act. Health Canada governs the vial. An authorized injectable drug carries an eight-digit Drug Identification Number; a product without one has not been assessed for safety, effectiveness or quality. Health Canada has repeatedly seized unauthorized and counterfeit injectables from spas and salons, and its wording about what is at stake is not softened: the potential risks of injecting an unauthorized botulinum toxin type A product range from mild local paralysis to death.

Four questions, anywhere you go

None of this asks you to read a practice guide before booking. Four questions cover it. Who will examine me, and is that person a physician? Will that examination happen in person? Who will perform the injection, and if it is not the physician, is a physician on site? And what product is going to be used?

A clinic that finds those questions awkward has told you something. If you want the treatment detail rather than the rules around it, the pages on neuromodulators and dermal fillers set out what each one does and does not do.