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subscription management page fields

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Is it possible to add additional form fields to a subscription management page, and to pre-populate the fields with data?

At the moment, by default-- it only allows the "Email" field to be used, which creates an empty email text field box.

We want to add more fields, which are mapped to CRM fields for a given contact record. Is this possible, and can this data be pre-populated?

See screenshot below:


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