In the past, it was common for makeup artists and hair stylists to make sweeping promises to aesthetic doctors/surgeons about referrals in exchange for discounted or gratis services. This practice seems to have now expanded into other groups, such as yoga instructors, nutritionists, massage therapists, personal trainers, and the list goes on. In fact, cosmetic patients often come in looking for a deal or a freebie with the promise that they are going to send all their friends. 

According to New York City plastic surgeon Darren Smith, MD, “As the beauty and wellness fields continue to expand in breadth and depth, the kind of providers making these promises and the numbers of those providers grows. Offers like this should be treated very carefully, however, as any arrangement that amounts to payment for referrals is unethical, and in many instances illegal.

“This is very common in New York, even on Park Avenue, but I shy away from arrangements like this for a few reasons. First, the best referrals are from happy patients, not just patients that got a discount. Second, promises like this are generally not reliable. Finally, anything like this would have to be carefully vetted to ensure it in no way amounts to paying for referrals,” adds Dr. Smith.

Michael Somenek, MD, a facial plastic surgeon in Washington, DC, faces similar offers. “With the commodization of many services that this industry offers, there are many people who are looking to propose a discounted service. The makeup artists and hair stylists are very much still the top offenders, but I have seen an increase in other types of providers, such as personal trainers. I do have patients that will propose that they receive a discount or gratis service just because they have many clients and friends themselves that they will send our way if satisfied with the service.”


From loyalty programs to perks to discounts, there are options for rewarding loyal patients. However, use caution when it comes to services in exchange for referrals. As Darren Smith, MD notes, the best referrals are from happy patients, not just patients that got a discount; promises are generally not reliable. Most importantly, it is illegal to pay for referrals, so assure any arrangements are on the up-and-up.

Dr. Somenek offers a case in point. “I recently had a personal trainer come in for a microneedling consultation. During the consultation, she informed me that she is on TV once a week and will promote me on TV and to all of her clients. Of course she was expecting to receive all three treatments for free (value of $3,500). I politely told her that I was happy to do the treatments for her and my patient care coordinator provided a cost analysis for her with a $500 discount. Without having a solid relationship with her or someone like that, there is no guarantee that they will follow through with anything.”

Key to managing such situations is to maintain a united front. “When they have an agenda to get a treatment for free, they usually start with me—who has little tolerance for it—and then attempt to reopen the discussion with our practice coordinator who provides the cost analysis and repeats that the price is the price,” Dr. Somenek says. “The staff knows that they are not allowed to authorize any exchange of services or any ‘deal' with a patient without my approval.”

Phil Werschler, MD offers some perspective from his Spokane, WA-based dermatology practice. “We have two hairdressers that receive discounted services for referrals, and they both bring us several new clients a year. Additionally, we did discounted services for two personal trainers, and they both sent new clients in, as well. One of these trainers actually applied for a front desk position and works for us part-time now, which has been great. She has affiliations with a completely different group in our home city, so it exposes our medical spa to many new potential clients. Moreover, we choose the people we want to work with very carefully,” he says. “I would decline to treat a patient if they weren't able to pay full price for their service; especially if they are a new patient and we don't know them at all. Fortunately, this isn't on the rise in our practice.”

Loyalty programs and VIP packages

Loyalty programs, VIP packages, and subscription initiatives are emerging as ways to keep patients coming back and staying loyal to your practice and to grow referrals. But do they work?

“We use Allergan's Brilliant Distinctions program, which essentially grants points when products are purchased. Allergan was very helpful in rolling this out in a seamless way; they set it up for our practice and trained the staff on how to enroll new patients,” says Dr. Smith. “I do think loyalty programs and subscription services are useful in patient retention and, most importantly, I think they can enhance patient care. These programs help establish a long-term forward-looking relationship such that a stepwise treatment plan can be developed to help a patient achieve his or her goals within a specified budget over a desired timeframe. I think these programs work well for any service that is periodic but I don't think they are widespread enough yet that patients expect them,” he adds.

Dr. Somenek says his practice doesn't have a loyalty program per se. “Instead, our loyal clients get incentives when they come into the practice. This isn't something that we advertise, but it certainly provides an extra touch when they come in and receive a little promotion or gift,” he explains. “I don't see a demand for a loyalty program, and I haven't ever had a patient even ask if we had one. The patients who are big supporters of your practice are always going to be supporters whether or not you offer a loyalty program. I think it's important to look at who your most loyal patients are and offer them something when they come in. It doesn't have to be anything large, and small things are enough to show your appreciation. This can range from a peel to a full-size skincare product they use or you want to introduce them to.”

Dr. Werschler offers his own loyalty program. “We have a loyalty program where the client builds up points based on how much they spend, and the points equal money they can spend in the spa at a later visit. The points are loaded onto a card (the Werschler Card) and the card is used as money in the spa. Each client is introduced to this when they check out of the spa—we have a brochure on how it works—or possibly the provider tells them about the program during the service. The front desk loads their points onto the card when they check out and they also ask if they have any points they want to use when they check out. Patients have been satisfied with this. I believe such programs do help to retain patients and develop loyalty to our practice. We use our loyalty program for all services. I don't think consumers expect it, but it is appreciated.”

Privacy Protection

In the age of HIPAA, it can be challenging to acknowledge referrals from patients ethically, without using patient names or encroaching on doctor-patient privilege. The experts explain how they navigate this.

Dr. Smith acknowledges, “This is a tricky one. What I will often do is ask the referred patient to thank the patient that referred them on my behalf if they are comfortable.” Dr. Somenek waits for a patient to bring up someone that they have referred to him. “Even when they do this, I never disclose anything about the patient. Instead I simply say thank you for thinking of me and express that I very much appreciate that. They usually understand and don't inquire if and what the patient has had done,” he adds.

“We found a HIPAA compliant system for monitoring this, where the patient that refers the friend has to have the other friend's permission, and it goes through this system,” says Dr. Werschler.


With the growth of social media, influencers abound. But it's unclear if and how they can benefit—or hurt—a practice. “I think the influencer needs to be able to show that they have a consistent amount of engagement with their followers. Just because someone has 50K followers doesn't mean that they are all legitimate or real. It really helps when an influencer has a target audience that is largely composed of people in your region. Targeting infuencers that are local is far more effective than having someone come in from a location that is across the nation or world,” notes Dr. Somenek.

“Think about what you're trying to achieve. Are you looking to increase the exposure of a procedure you offer? Are you looking to increase a general awareness of your practice? For instance, one of the influencers that I worked with had a following in my region largely composed of a 20- to 40-year-old demographic. Because of that, I wanted to focus on injectables, because that is the most common procedure patients that age are likely to come in for and I wanted to demystify the misconceptions that people have about getting a neurotoxin or filler treatment,” he adds.

Dr. Somenek has worked with a few influencers over the past year and notes that they are an interesting group to work with, “because they have built a career of promoting things on social media. I have had what I would consider a neutral experience with them. I quickly realized that in order to effectively do business with them, you need to establish a set of expectations. That includes a contract that is signed by them and you to ensure that they hold up to their side of the bargain. All too commonly they will receive a reduced or free service from a physician and never be seen again. Even when I had a contract with one of my influencers, I still had to send emails asking when his blog and other agreed terms were to be completed. At the end of the day, everything was finished to my satisfaction. It helped my social media presence to a certain extent, but you definitely need to be careful to not be taken advantage of.”

“It is very rare to trace a specific patient to an influencer. This is because even if a patient does come in because they saw my services promoted by an influencer on Instagram, they are more likely to say they found me on Instagram than they heard about me from ‘Influencer X.' Alternatively, it could be that influencer marketing is more effective for brand awareness than for direct referrals,” suggests Dr. Smith. “I think superstars and micro-influencers are the most valuable to work with. The value of a superstar endorsement is obvious. The value of a micro-influencer is that they have the potential to be precisely targeted such that their audience is comprised of people that can actually benefit from and be interested in your services. I am wary of mid-level influencers that may have many followers that aren't that relevant to my practice.”

Dr. Werschler takes a more conservative approach. “We don't work with influencers unless we know them and they have a good track record in the community and they are for real,” he says.

Proceed Cautiously

According to Jeremy Green, MD, a dermatologist in Miami, “The true influencers my partners and I see in Miami are people who could move the needle of patient demand with a single social media post. These people are recognized in public, and with rare exceptions prefer not to advertise their aesthetic treatments. Out of respect for them (and patient privacy laws!) we maintain discretion. I have a healthy amount of skepticism for other influencers. They can be great and charming people, but those who I have encountered tend to bounce around town seeing whoever will give them a complimentary treatment. Their accounts may provide education regarding results and the patient experience, but I've yet to see boots on the ground respond to their posts. Moreover, in this world of fake followers, fake news, and fake everything, sometimes it's difficult to ascertain who has a legit following versus those ‘influencers' who purchase their popularity.

“My most negative experience with an ‘influencer' was early in my career, when someone in the beauty industry claimed to be able to send her celebrity clientele. I spent a ton of time with her and thought we had become fast friends. When she refused pre-treatment photography I said no big deal, treated her, and off she went. A couple of weeks later she showed up furious with the result. She looked great, but without before pictures I had no legs to stand on. I treated her to pacify her, and learned my lesson the hard way. Chances are this ‘influencer' jumps from practice to practice in Miami seeking free treatments from other naïve docs like I was. From that day on the only influencer who can skip pre-treatment photos in my practice is my mother!” says Dr. Green.