Online Forms

At Lasting Impressions, we know how valuable your time is, and we know that when you visit our practice for a dental appointment, prompt service is important to you. The following forms are here for your convenience. In order to save you time during your visit with Lasting Impressions, please print out these forms, complete them and bring them with you to your appointment. 

Please contact our office at (518) 438-1131 if you have any questions, or if you need help completing any of these forms.



General Information Form

New Patient Information.pdf
Adobe Acrobat document [1.3 MB]

X-Ray Release Form

If you have any questions or need additional information, please call us at (518) 438-1131. If you need to schedule an appointment, we offer convenient hours that will fit your schedule. We are conveniently located at 399 Albany Shaker Road in Loudon Square, Loudonville, New York, 12211.

Contact Lasting Impressions to schedule your next appointment:


Dr. Mark J. Polsinello, DMD

Lasting Impressions

399 Albany Shaker Road

Loudon Square

Loudonville, NY 12211

(518) 438-1131




Open Monday-Thursday 8:30am-5:00pm

and Fridays(once a month)

Emergencies Always Taken!

Lasting Impressions is a participating dental provider in the Delta Premier ,Cigna PPO

and Metlife Dental Plans

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Lasting Impressions