Application for Insulin Potentiation
Therapy (IPT) Training Program
Please print clearly. Complete this form, sign and return.
Last Name: ______________________________First Name: _____________________________
Date of Birth: (mm/dd/yyyy): ____/____ /_______
License type, Number, and State: _________________________________
Office address: ____________________________________________________________________
City, State: ___________________________________________ Zip/Postal Code: ______________
Country: ______________________________________ Fax: ______________________________
Telephone: ____________________________ Web: _____________________________________
E-mail address: _______________________________________________________________
I, _________________________________ (name), a licensed _______________________________
practicing in the city(ies) and state(s) of __________________________________________________,
do hereby understand, acknowledge, affirm and agree to the following:
1. I certify that my license (medical / osteopathic / veterinary medicine) is in good standing and permits
me to practice the IPT procedure in my local jurisdiction.
2. My completion of the IPT training course grants me unrestricted license without royalty to practice and
administer IPT in my own medical/osteopathic/veterinary practice and will permit my name and
information to be added to the listing of certified IPT practitioners on the official international IPT
professional website (IPTforcancer.com), upon payment of fees to the site and official IPT organization
(International Organization of Integrative Cancer Physicians: IOICP).
3. I shall not organize or build another website with the intention to compete with IPTforcancer.com in its
role as the official IPT website, particularly its listings of all certified IPT practitioners and instructors. My
website(s) and printed materials about IPT shall always have a clear and obvious link or reference to
IPTforcancer.com as a source for more information about IPT.
4. I shall not organize any IPT medical association or IPT training courses or workshops that are
independent of the IOICP or Best Answer for Cancer Foundation (BACF).
5. I shall not organize any organization with the intention to compete with Best Answer for Cancer
Foundation in its role to spread awareness of Integrative Oncology: IPT/IPTLD + integrative cancer care.
6. I shall not disclose any information, programs, processes, etc. that are the property of the IOICP or
Best Answer for Cancer Foundation.
7. I shall not disseminate practical information, teach, or provide any literature or information to any
other health professional under any circumstances except as described below.
Application for Insulin Potentiation Therapy (IPT) Training
Program
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8. I may properly instruct my nurse(s) on proper medical administration of IPT and another medical
professional who is covering for me, the necessary information to competently administer the therapy in
my absence. Such individuals, even an associate of mine, must sign a non-disclosure/non-compete
agreement with me stating that he/she shall not practice IPT outside my office unless he/she attends a
proper training course in the therapy approved by Best Answer for Cancer Foundation and the IOICP).
In addition, this medical professional can only appear in my listing on the IPT website if they attend a
proper training course in the therapy now under management control of the IOICP. My permission to
state that I am an IPT practitioner may be suspended or revoked by the IOICP and/or BACF if I violate
any of the provisions of this agreement.
9. I will submit case reports with follow-up for some IPT patients to the Medical Advisory Board of the
IOICP for the authorized IPT Case Registry.
10. I shall be financially responsible to the IOICP and BACF for any violations by me of this agreement.
Any alleged violations shall be subject to prior written notification and opportunity to respond.
Signed: ________________________________________________________________
Date (mm/dd/yyyy): ____/____ /_______
IPT/IPTLD Training Program Sponsored by Best Answer for Cancer Foundation, a 501c3, and
International Organization of Integrative Cancer Physicians (IOICP) effective November 2009.
Application for Insulin Potentiation Therapy (IPT) Training
Program
2