Medical and dental appointment leave application and decision record
- Version
- v1
- Updated
- 7 October 2026
- Reviewed
- 7 October 2026
- Audience
- Primary and secondary schools in England, including maintained schools and academies, excluding independent schools.
- Jurisdiction
- england
Blank fields · read-only preview
Use this form for an advance request for leave for a medical or dental appointment. Schools should encourage appointments outside school hours and limit absence to the minimum time necessary. Where regulation 11 applies, the application must be made in advance by the parent the pupil normally lives with, or by the pupil where applicable, and exceptional circumstances must justify granting the leave.
Pupil and application details
Pupil name
RequiredEnter the pupil's full name.
Full name
Year group or class
RequiredEnter the pupil's current year group or class.
Year group or class
Date of application
RequiredRecord the date the request was submitted. The application should be made in advance.
- Day
- Month
- Year
Applicant name
RequiredEnter the name of the person making the application.
Applicant's full name
Applicant's capacity
RequiredSelect the applicable relationship or status. A pupil may apply where the pupil will be over compulsory school age by the time of the absence.
Choose one
- Parent the pupil normally lives with
- Other parent
- Pupil, where applicable
- Other applicant
- Other
If other, please specify
Appointment and requested absence
Appointment type
RequiredSelect the type of appointment for which leave is requested.
Choose one
- Medical appointment
- Dental appointment
Appointment date
RequiredEnter the date on which the pupil is expected to be absent for the appointment.
- Day
- Month
- Year
Requested absence duration in minutes
RequiredRecord the minimum amount of time requested for the appointment and necessary travel or attendance arrangements.
Number
Minimum: 1 · Maximum: 1440
Relevant appointment details
Provide only information needed to assess the request, such as the expected appointment time or travel arrangements. Do not include unnecessary medical information.
Relevant details
Regulatory applicability and decision
Does regulation 11 apply to this school for this request?
RequiredSelect the status applicable to the school and this request.
Choose one
- Yes, regulation 11 applies
- No, regulation 11 does not apply
- Not yet confirmed
Where regulation 11 applies: exceptional circumstances supporting the request
Complete this field only where regulation 11 applies. Record the individual facts relied on when deciding whether exceptional circumstances justify the leave.
Record the relevant individual facts
Decision on the leave request
RequiredRecord the decision. Where regulation 11 applies, grant leave only where the application was made in advance by the appropriate applicant and exceptional circumstances justify it.
Choose one
- Leave granted
- Leave refused
- Decision pending
Decision reasons and conditions
RequiredRecord the reasons for the decision and any conditions, including the approved minimum absence where leave is granted.
Decision reasons and conditions
Approved absence duration in minutes
Complete where leave is granted. Record only the minimum time necessary for the appointment.
Number
Minimum: 1 · Maximum: 1440
Attendance recording
Was the pupil present at registration before leaving for the appointment?
RequiredIf the pupil was present at registration and then left for the appointment during that session, no absence needs to be recorded for that session.
Choose one
- Yes, present at registration before leaving
- No, not present at registration
- Not applicable
Where leave is granted: has Code M been recorded?
Complete where medical or dental appointment leave has been granted. Schools not required to follow regulation 11 must still use Code M for granted leave of this type.
Choose one
- Code M recorded
- Code M not yet recorded
- Not applicable because leave was not granted
Attendance recording notes
Record any relevant session, registration, or attendance-recording information.
Attendance recording notes
Decision record
Decision-maker name and role
RequiredEnter the name and role of the person recording the decision.
Name and role
Decision date
RequiredEnter the date on which the decision was recorded.
- Day
- Month
- Year