La. Stat. tit. 9 § 4231
The decisions to enter into a medical or dental contract shall be voluntary on the part of the patient, and on the part of the medical or dental practitioner. If both parties voluntarily agree to enter such a contract, the following but not necessary or exclusive provisions of such contract shall be valid, irrevocable, and enforceable, save upon such grounds as exist at law or in equity for the revocation of any contract. The following contract is merely a sample and the provisions therein are not required as a matter of law to be included in arbitration agreements under this Chapter.
ARBITRATION AGREEMENT
______________, hereinafter called "Patient", engages ______________, hereinafter called "Medical or Dental Practitioner", to render medical care and service. For and in partial consideration of the rendition of any and all present and future medical care and service, the patient agrees that in the event of any controversy arising out of claims based on negligence or medical malpractice, between patient, whether a minor or an adult, or the heirs at law or personal representatives of a patient, as the case may be, and medical or dental practitioner, including his agents or employees, the same shall be submitted to arbitration. Within fifteen days after any of the above named parties shall give notice to the other of demand for arbitration of said controversy, the parties to the controversy shall each appoint an arbitrator and give notice of such appointment to the other. Within fifteen days after such notices have been given, the two arbitrators so selected shall select a neutral arbitrator who is an attorney, licensed to practice in the state of Louisiana, and give notice of the selection thereof to the parties. The arbitrators shall hold a hearing within ninety days of the date of notice of selection of the neutral arbitrator. All notices or other papers required to be served shall be served by certified United States mail. Except as herein provided, the arbitration shall be conducted and governed by the provisions of the Louisiana Arbitration Law, R.S. 9:4201 et seq. The taking of testimony and presentation of evidence at the arbitration hearing shall be governed by the general rules of evidence applied in the courts of Louisiana.
This agreement shall become effective on the ______ day of ________ 20___, and expire five years thereafter. Nevertheless, any dispute arising from an act or omission occurring during the term of this contract shall be resolved in accordance with this contract regardless of when the dispute arises. This agreement applies to the rendition of all present and future medical or dental care and service by medical or dental practitioner within the term of this contract.
______________, 20___ By ___________________________________
Medical or Dental Practitioner ______________, 20___ By ___________________________________
Patient
By ___________________________________
Parent or Guardian
if patient is a Minor
La. R.S. § 9:4231