VAT on physiotherapy in Spain: when it is exempt and how to invoice

A patient asks for an invoice for their ten-session pack so they can send it to their health insurer. The local football club wants you to bill it every month for treating its players. And a neighbour asks whether you will be running Pilates classes in the evenings. That is three payments to the same physiotherapist, and each one is treated differently for VAT.

This guide explains VAT on physiotherapy in Spain through everyday cases: which sessions are exempt, which ones carry 21%, when you need to apply income tax withholding and what a physiotherapy invoice has to include. It is all based on the Spanish VAT Act, the invoicing regulation and the binding rulings of the Directorate General of Taxation (Dirección General de Tributos, DGT). It is general information, so check any unusual case with your accountant (gestoría).

Does physiotherapy carry VAT in Spain?

Not when it is healthcare. Article 20.One.3 of Law 37/1992 (in Spanish), the VAT Act, exempts care given to individuals by medical or health professionals, whoever the recipient of the service is. Physiotherapists are health professionals, and the exemption covers care related to the diagnosis, prevention and treatment of illness.

The tax authorities require two conditions at the same time. The first is about the service, which has to aim to diagnose, prevent or treat an illness or an injury. The second is about who provides it, who must be a health professional, in this case a qualified physiotherapist. If either condition fails, the session carries VAT.

When both are met, VAT-exempt physiotherapy covers more situations than you might expect:

• it does not matter who pays, so the session stays exempt whether the patient, their employer, an insurer or a sports club pays for it;
• it is also exempt if you work through a company or if you invoice your sessions to the clinic where you see patients;
• no prior medical referral is needed, as long as the service is a treatment.

Which physiotherapy services are VAT-exempt

In 2013, the body that represents Spain's professional associations of physiotherapists (colegios) asked the DGT how the profession's services should be taxed. Its answer, binding ruling V0679-13 (in Spanish), is still the reference point, and the tax authorities have repeated the same view in later rulings. Under that approach, the following are exempt:

• physiotherapy treatment with a therapeutic purpose, such as manual techniques, therapeutic exercise, dry needling, electrotherapy or rehabilitation after surgery or a sports injury;
• osteopathy, hydrotherapy and therapeutic exercise or rehabilitation when a physiotherapist provides them;
• group treatment with a therapeutic purpose, including rehabilitation using Pilates techniques, the Gyrotonic method or hypopressive abdominal exercise (ruling V1152-22);
• services that are ancillary to an exempt treatment, such as the reports on players' progress that a physio prepares for the coaching staff of the club that pays them (ruling V2277-11).

What decides it is the purpose, and the simplest way to prove the purpose is to have it in writing. If each patient's clinical record includes the initial assessment, the goals and the progress of every session, it will be easy to show that those sessions were treatment.

When a physiotherapist has to charge VAT

If a service does not aim to diagnose, prevent or treat, it loses the exemption and is invoiced at the standard rate of 21%, even when a physiotherapist does it on their own treatment table. These are the most common cases in a practice.

Cosmetic or relaxation massage

A massage to relax, a slimming method or a session with a cosmetic aim, with no injury or health problem behind it, carries VAT. The tax authorities say so explicitly about massages given by physiotherapists for purely cosmetic or relaxation purposes. The same massage, as part of treating a muscle contracture or an injury, stays exempt. What changes is the reason the patient is on the table.

Pilates and exercise with no therapeutic aim

For the Spanish tax authorities, Pilates is a sport, so Pilates classes are taxed at 21%. The nuance comes when it is part of a treatment. Ruling V1152-22 accepts the exemption for rehabilitation using Pilates techniques delivered by physiotherapists, and in June 2026 ruling V1451-26, about a clinic that wanted to offer Pilates to prevent injuries and maintain fitness, repeated the test: it is only exempt if it aims to diagnose, prevent or treat an illness. A Pilates class open to anyone who wants to get fit carries VAT. The same goes for personal training and group fitness classes.

Expert reports for third parties

An expert report for a court case, a damages claim or an administrative procedure carries VAT, even if you need to examine the patient to write it. Its purpose is to help someone else take a decision with legal effects, and the Court of Justice of the European Union left this kind of report outside the exemption (case C-212/01). Ruling V0679-13 applies that to expert reports by physiotherapists.

Selling products and renting out a room

If you sell products at your practice, such as creams, resistance bands or foam rollers, those sales are not healthcare and carry whatever VAT rate applies to each product. The same goes if you rent a treatment room to another professional: the VAT Act only exempts the rental of housing and land, so renting business premises is invoiced at 21%.

If you combine exempt sessions and services with VAT

As long as everything you do is exempt, VAT creates very little paperwork. You do not file the quarterly VAT returns (Form 303) or the annual summary (Form 390), because the VAT regulation releases taxpayers who only carry out exempt transactions from that obligation. The flip side is that you cannot recover the VAT you pay on purchases (the treatment table, the rent, your practice software), so it simply becomes another cost.

Once you add something with VAT, such as a Pilates group or product sales, several things change. You have to file VAT for that part every quarter, and you can only deduct part of the VAT on your expenses, under the pro rata rule in articles 102 onwards of the VAT Act. You also need to register the new activity with the tax office: according to ruling V1152-22, Pilates taught as a sport goes under heading 967.2 of the business activity tax (IAE). Before you launch the service, ask your accountant to run the numbers, because adding 21% to the price of each class is noticeable.

Income tax withholding on a physiotherapy invoice

Withholding (retención de IRPF) is an advance payment of your income tax that the payer deducts from your invoice and then pays to the tax office on your behalf. Only companies and other organisations, and professionals and businesses paying you as part of their activity, are required to withhold. A private patient never withholds, so their invoices carry no withholding.

If a company, a sports club, an insurer or the clinic you work for as a self-employed physio pays you, your invoice carries income tax withholding of 15%. If you are just starting out, it can be 7% in the year you start and the following two, as long as you did not carry out any professional activity the year before. To apply the 7% rate you must tell the payer in writing, and they have to keep that signed notice (article 95 of the Income Tax Regulation).

Two more details are worth knowing. Withholding applies to professional activities, the ones in section two of the IAE, where physiotherapists have group 836. If your activity is registered as a health centre under heading 942.9, which belongs to section one, the tax authorities treat it as a business activity, and those invoices, in principle, carry no withholding (we explain this in our guide on how to open a physiotherapy clinic in Spain). And if at least 70% of your income had withholding the year before, for example because you bill almost everything to a clinic, you do not have to file the quarterly instalments on Form 130 (article 109 of the same regulation).

What a physiotherapy invoice must include

An exempt session still needs an invoice, because the invoicing regulation requires one for exempt healthcare too. Under article 6 of Royal Decree 1619/2012 (in Spanish), a full invoice includes:

• a number and, if you use more than one, a series, numbered consecutively within each series;
• the date of issue and, if different, the date of the sessions;
• your full name, your tax ID (NIF) and your address;
• the full name, tax ID and address of the patient or whoever pays;
• a description of the service, with the price per session before tax and any discounts;
• the VAT rate and amount or, if the session is exempt, a reference to the exemption.

If there is withholding, it is subtracted at the end to reach the amount you are paid. For the exemption, a line such as "Operación exenta de IVA según el artículo 20.Uno.3.º de la Ley 37/1992" (VAT-exempt under article 20.One.3 of Law 37/1992) is enough. The description does not need a diagnosis: "Physiotherapy session" and the date will do, so the invoice carries no more health data than necessary.

If the amount is no more than 400 euros including VAT, you can issue a simplified invoice (factura simplificada, what used to be called a ticket) without the patient's details (article 4 of the same regulation). When a patient asks for an invoice in their name, for example to claim the money back from their insurer, give them a full invoice with their tax ID and address.

Two rules remain. If you make a mistake on an invoice you have already issued, do not delete or change it: you correct it with a corrective invoice (factura rectificativa), which goes in its own series. And if a patient pays for a session pack in advance, the regulation requires an invoice for that advance payment too.

Four everyday cases, solved

1. A patient pays in advance for a ten-session pack to treat tendinitis. The invoice is VAT-exempt, has no withholding and is issued when you receive the payment.
2. A youth football club pays for treating its injured players. The invoice is VAT-exempt with 15% withholding, or 7% in your first years, because the payer is an organisation.
3. You work as a self-employed physio at a clinic and bill it every month for the sessions you did there. It is still healthcare, so it is exempt, and it carries withholding because the clinic pays you as part of its activity.
4. You start an evening Pilates group for people who want to keep fit, with no assessment or treatment behind it. The classes carry 21% VAT, you file VAT every quarter and you need to register that activity with the tax office.

VeriFactu: what changes in 2027

Royal Decree 1007/2023 requires invoicing software to record every invoice in a chained log that cannot be altered afterwards, and the invoice must carry a QR code that can be checked on the Tax Agency's website. Under the dates currently in force, companies must comply from 1 January 2027 and self-employed professionals from 1 July 2027. On 5 October 2026 the Ministry of Finance announced that it plans to postpone this to October 2028, but until that is published in the Official State Gazette (BOE) the 2027 dates still apply.

If you currently invoice by hand or with a template, now is a good time to move to software that is ready for VeriFactu, so you reach July 2027 with your invoice series already up and running.

Physiotherapy invoices in My Fisio Agenda

In My Fisio Agenda, invoicing sits in the same diary where you book appointments. Completed sessions move to "Unbilled sessions" on their own, and you create the invoice from there without copying anything. Everything above is already covered:

• the healthcare VAT exemption is ticked by default and the PDF cites article 20.1.3 of Law 37/1992; if a service is not exempt, you untick it on that invoice and apply VAT;
• you choose the income tax withholding on each invoice (7%, 15% or whatever applies to you) or set a default;
• if the patient's record has "Bill a Company" switched on, the invoice shows the registered name and tax ID of the company or club;
• for a patient who is a minor, you invoice guardian 1, guardian 2 or split it 50/50;
• if the patient does not give you their ID number, the invoice is issued as a simplified one, as long as it is no more than 400 euros;
• the number and date are assigned on issue, using the next number in your series, and mistakes are corrected with corrective invoices in their own series;
• you download each invoice as a PDF or as a signed Facturae file.

Every invoice you issue is recorded, chained and signed in the app, and whenever you like you can switch on VeriFactu mode so that each record is sent to the Tax Agency with your digital certificate. Every plan includes invoices: 20 a month on Semilla (€4.99), 100 on Junior (€19.99) and unlimited on Senior (€29.99), VAT not included and with no minimum term. You will find the details on the VeriFactu invoicing for physiotherapists page, and everything else this software for self-employed physiotherapists does on its own page.

It runs in the browser on your computer, tablet or phone, with nothing to install. You can try it free for 1 month, no card needed, and issue your first invoices from day one.

FAQ on VAT and physiotherapy in Spain

Short answers to the questions physiotherapists ask most about VAT, income tax withholding and invoices.

Does physiotherapy carry VAT in Spain?

Not when it is healthcare. Physiotherapy treatment that aims to diagnose, prevent or treat an illness or an injury is exempt under article 20.One.3 of Law 37/1992, whoever pays for the session. Services without that purpose, such as a relaxation massage or a Pilates class to keep fit, carry 21% VAT.

Do I have to issue an invoice if the session is VAT-exempt?

Yes. The invoicing regulation (Royal Decree 1619/2012) requires an invoice for exempt healthcare too. If the amount is no more than 400 euros including VAT, it can be a simplified invoice without the patient's details.

What wording should the invoice use for the VAT exemption?

Citing the article that sets it out is enough, for example "Operación exenta de IVA según el artículo 20.Uno.3.º de la Ley 37/1992". The invoicing regulation also accepts simply stating that the transaction is exempt.

Does Pilates taught by a physiotherapist carry VAT?

It depends on its purpose. The Spanish tax authorities treat Pilates as a sport, and classes to keep fit are taxed at 21%. If it is part of a patient's treatment or rehabilitation, it can be exempt as healthcare, according to rulings V1152-22 and V1451-26 of the Directorate General of Taxation.

What income tax withholding goes on a physiotherapist's invoice?

None if a private patient pays you. If a company, a club, an insurer or a clinic pays, the standard withholding is 15%, or 7% in the year you start and the following two, as long as you tell the payer in writing.

Can I deduct the VAT on my purchases if my sessions are exempt?

No. If you only carry out exempt transactions, you do not charge VAT and cannot deduct the VAT you pay on purchases, which becomes another cost. In return, you do not file the VAT returns on Forms 303 and 390.

When do I have to use VeriFactu-ready software?

Under the dates in force, from 1 July 2027 if you invoice as a self-employed professional and from 1 January 2027 if your clinic is a company. In October 2026 the Ministry of Finance announced it plans to postpone this to October 2028, but until that is published in the BOE the 2027 dates apply.