What should a medical director agreement cover in Ontario?

“Medical director” isn’t a licence category in Ontario. It’s a title clinics give to the physician or nurse practitioner whose authority lets nurses and other staff perform treatments that involve controlled acts. CNO’s Aesthetic Services guideline treats it as a practice-setting title, like “nurse injector”. The agreement should describe what that person actually does.

What does a medical director do in an Ontario med spa?

They are the authorizing provider. Registered nurses and registered practical nurses can perform procedures such as cosmetic injections only when the procedure is ordered by an authorized person, which under section 5 of the Nursing Act, 1991 includes a physician and a nurse practitioner. Physicians can also delegate controlled acts to people who aren’t authorized to perform them, including unregulated staff, under section 27 of the Regulated Health Professions Act, 1991 and CPSO’s Delegation of Controlled Acts policy.

Order, directive or delegation?

Mechanism	What it is	Typical use in a med spa
Direct order	Written or verbal instructions for a specific client, for a specific treatment	A physician or NP assesses a client and orders a specific treatment
Directive	A written order that applies to any client who meets set conditions	Standing instructions for a defined treatment, with criteria and contraindications
Delegation	Temporary transfer of authority to perform a controlled act to someone not authorized to do it	Strict college requirements apply, and CNO is reviewing its use in aesthetics

CNO’s orders, directives and delegation FAQ explains that when a nurse implements a directive, the nurse assesses whether the client meets its criteria. CNO’s guideline says an authorizing mechanism must be clear, complete and appropriate, with appropriateness based on an assessment of the client’s health history, contraindications and a physical assessment. CNO has also said it is actively reviewing how directives and delegation are used in aesthetics, so the agreement should require both sides to follow changes when they take effect.

What must a medical directive include?

For physicians, CPSO’s policy lists what a medical directive must contain:

• The name and description of the procedure, in enough detail for safe implementation.
• The specific clinical conditions the patient must meet, and any situational circumstances that must exist.
• A complete list of contraindications.
• Who is authorized to implement it.
• The name and signature of the authorizing physician and the date it takes effect.
• Any administrative approvals, with dates.

How involved does the medical director have to be?

More than a name on the door. When a physician delegates a controlled act, CPSO’s policy requires them to:

• Delegate only in an existing or anticipated physician-patient relationship, and clinically assess each new patient before delegating or, where that isn’t possible, within two business days of the delegate starting the controlled act, outside listed exceptions.
• Be physically onsite to supervise, unless the risk is low or another physician who can support the delegate is onsite, and otherwise be available to help on short notice.
• Make sure patients know who the delegating physician is, and can ask to speak to them.
• Have protocols for adverse events and an ongoing system to monitor delegates, including reviewing records.
• Not delegate when the main reasons are monetary gain or convenience.

For nurse practitioners, CNO’s guideline says NPs should be actively involved with the team carrying out their aesthetic orders, decide when their direct involvement or supervision is needed, assess whether remote or virtual prescribing is suitable, and be able to manage adverse outcomes.

What clauses should the agreement have?

Clause	What it should settle
Parties and credentials	The director’s registration, any terms on their certificate, and their insurance
Services	Which treatments the director authorizes, and which they don’t
Orders and directives	Who drafts them, how often they’re reviewed, who may implement them
Assessment	Who assesses each new client, when, and how follow-ups are triggered
Supervision and availability	Onsite days, response times, and backup cover when the director is away
Staff competence	How injectors’ training and competence are confirmed before they act
Products and equipment	Health Canada-approved products only, with storage and handling rules
Adverse events	The emergency plan, who is called, and how events are recorded and reported
Records and privacy	Who keeps clinical records, and who is the health information custodian
Advertising and use of name	How the director’s name and title appear in marketing, and who approves it
Fees	A fee for the director’s services, set out in writing
Clinical independence	The director’s clinical judgment can’t be overridden by business targets
Term and exit	Notice periods, and what happens to directives, records and bookings when the director leaves

How should a medical director be paid?

Write it down, and have the director check it with their college and insurer. The Medicine Act regulations make it professional misconduct for a physician to share fees with a person who referred a patient, or to accept a rebate or commission for a referral (O. Reg. 856/93). They also treat some arrangements as conflicts of interest, such as renting premises to or from certain suppliers unless the rent is normal for the area and isn’t tied to the volume of business or to referrals, and selling drugs to patients at a profit outside narrow exceptions (O. Reg. 114/94, s. 16). CNO’s guideline also warns nurses against incentives tied to selling volumes of specific products or injections.

What about the director’s name in ads?

Physicians must follow rules on how their name appears in advertising: under section 9 of O. Reg. 114/94, it must be followed by their recognized specialty or the title “General Practitioner”. CNO’s guideline says nurses’ aesthetic advertising should include the name of their authorizing provider or medical director. Agree in the contract who approves marketing that names the director.

What to do next

We review medical director agreements, and the practitioner agreements that sit alongside them, as a contract review, starting at $400. A new medical director and practitioner agreement drafted for your clinic starts at $600. See also who can own a med spa in Ontario and who can perform Botox and filler injections.

This guide is general information about Ontario law, not legal advice for your situation. The director should also confirm the arrangement meets their own college’s current standards. To talk through your agreement, book a free 15-minute consult.