Med spa marketing agencies charge in one of three shapes: a flat monthly retainer, a percentage of what you spend on ads, or a fee tied to leads or patients delivered. Each one pays the agency for something different, and the difference decides what the agency does in the month your budget changes.
The three fee models, and what each one buys
A flat retainer buys a defined scope of work for a fixed monthly number. A percentage of ad spend buys management priced as a share of your media budget. A performance fee buys delivered volume, billed per lead, per booked consult or per patient. The table sets out what each one rewards, and what each does when your budget moves.
| Fee model | What you are paying for | What the fee rewards | If you double the ad budget |
|---|---|---|---|
| Flat retainer | A defined scope for a fixed monthly fee | Efficiency: the same fee covers the work whichever budget it runs on | The fee does not move, so the larger buy earns the agency nothing extra |
| Percentage of ad spend | Management priced as a share of the media budget | Spend: the fee rises with the budget whether or not the budget booked a consult | The fee rises roughly in step with the budget |
| Per lead or per patient | Delivered volume, billed by the unit | Unit count, which is not the same as kept consults | The fee follows the count, and the basis raises the legal question below |
| Hybrid: flat plus a share above a threshold | A base scope, plus a spend-linked slice on the part above the line | Both, in whatever proportion the contract sets | The flat part holds; the share applies only above the threshold |
None of the four is dishonest by construction: a percentage is defensible where the work genuinely scales with the buy. You are choosing an incentive as well as a number, and the incentive is the part nobody puts on the proposal.
A percentage prices your agency's fee off your media budget
A percentage fee ties what you pay the agency to what you pay Google and Meta, so the agency's revenue grows when your budget grows, whether or not the extra budget produced a consult. The recommendation to raise spend then comes from the party whose income the raise increases, which is worth knowing before the conversation, not after.
The second problem is arithmetic, and it is worse at the budgets med spas actually run. Growth99's 2026 State of Aesthetic and Elective Wellness Marketing Report, published by the American Med Spa Association in January 2026, found 52% of med spa practices investing under $2,500 a month in marketing and only 25% at or above $5,000. A share of a budget that size is a small number that still has to fund strategy, creative, landing pages and reporting.
For the budget context behind that, AmSpa's 2024 Medical Spa State of the Industry Report puts the average med spa's marketing investment at about 7% of revenue, inside a 2% to 15% range. Against numbers like those, a percentage fee pays the agency well at the top of the range and underfunds the work at the bottom, where most practices sit.
A fee based on results is a different question for a medical practice
A fee billed per lead, per booked consult or per patient is not only a pricing preference in aesthetics. Because the payment is triggered by a patient arriving, it can look like paying for a referral, and most states restrict that for medical practices. The caution attaches to the basis of the fee, not to advertising itself.
Patrick O'Brien, J.D., legal coordinator for the American Med Spa Association, writes that "Paying for advertising based on results or consumer response always will appear to be a paid referral and is certainly a risky arrangement." The same article notes that New York prohibits a licensee from offering, giving or receiving any fee or consideration to a third party for the referral of a patient, and that New York and Texas are not alone, as of September 2026.
North Carolina polices the ownership side of the same principle. The North Carolina Medical Board's position statement on the corporate practice of medicine, adopted March 2016 and amended September 2025, states that businesses practicing medicine in the state must be owned in their entirety by North Carolina licensees, and that licensees providing services for lay-owned businesses may face discipline. Whether a specific fee arrangement crosses a line is a question for your healthcare attorney, and this article is educational marketing guidance rather than legal or medical advice.
What Google already requires an agency to tell you about its fee
Google's third-party policy requires an agency charging a management fee on top of Google Ads costs to tell new customers in writing before the first sale and to disclose the fee on invoices. Reported cost data must show the exact amount Google charged, exclusive of the agency's own fees, as of September 2026.
The policy goes further for small accounts: where 80% or more of a third party's customers spend under $1,000 a month on Google Ads, that third party is required to share a disclosure notice with all of its Google Ads customers. Plenty of med spa engagements sit in exactly that band.
Asking what the fee is in dollars, separately from media, is therefore not an awkward question. It is what Google's own policy says an advertiser is owed, and one blended number on a monthly report is the tell that you are not getting it.
Five questions that expose a fee model before you sign
Fee models rarely announce themselves on a proposal, so ask the questions whose answers only one model can give. Each of these has a right answer and a revealing one, and none of them requires you to know anything about marketing. Ask every agency you talk to, including this one.
- What does your fee do when I double the ad budget? A flat fee holds; a percentage roughly doubles; a hybrid moves only above the threshold.
- Is the fee flat, or a percentage of what I spend on ads? Ask for the number in dollars per month, not a band.
- What did Google and Meta charge last month, separate from what you charged? Google's policy says the platform figure is reported exclusive of agency fees.
- If you bill per lead, what counts as a lead and what happens to a duplicate? The definition is the price.
- Whose name is on the ad accounts, and what is owed if I leave? Account ownership and exit terms belong in the same conversation as the fee.
What this looks like when it runs
Is the fee flat, or a percentage of what I spend on ads? Flat. Mirastart runs a flat monthly retainer from $3,000, never a share of ad spend, so doubling the media budget never raises the fee. Platform cost is reported as Google and Meta charged it, separate from the retainer, which is the shape Google's policy describes.
Under that fee sits the operational half a med spa's revenue leaks through, running in production for Charlotte businesses today: booking that calculates live availability and confirms automatically, follow-up that chases the inquiry nobody answered on Saturday, review requests sent to everyone at the same milestone, and reporting counted in consults booked and kept. The accounts stay in the practice's name, so leaving is a handover rather than a rebuild.
Sources
- Google third-party policy (Google Advertising Policies Help) - Third parties charging a management fee separate from Google Ads costs must inform new customers in writing before the first sale and disclose the fee on invoices; advertising cost data must be reported as the exact amount charged by Google, exclusive of third-party fees; a disclosure notice is required where 80% or more of a third party's customers spend under $1,000 a month.
- You Can't Pay for Patients and Call it Marketing, Patrick O'Brien, J.D. (American Med Spa Association) - Paying for advertising based on results or consumer response always will appear to be a paid referral; New York prohibits a licensee from offering, giving or receiving any fee or consideration to a third party for the referral of a patient, and is not alone.
- The Marketing Investment Gap (American Med Spa Association, January 9, 2026) - Growth99's 2026 State of Aesthetic and Elective Wellness Marketing Report: 52% of med spa practices invest less than $2,500 a month in marketing; only 25% meet or exceed $5,000. Survey size and method are not stated on the page.
- Industry Experts Weigh In to Help Answer, How Much Should I Spend on Med Spa Marketing? (American Med Spa Association, May 2, 2025) - AmSpa's 2024 Medical Spa State of the Industry Report: the average med spa invests about 7% of revenue in marketing, within a 2% to 15% range.
- Position Statement 10.1.2: Corporate Practice of Medicine (North Carolina Medical Board) - Adopted March 2016, amended September 2025: businesses practicing medicine in North Carolina must be owned in their entirety by North Carolina licensees, and licensees providing services on behalf of lay-owned businesses may be subject to discipline.