[MM_Form type=’myaccount’]
[MM_Form_Message type=’error’]
Practice Name: [MM_Member_Data name=’customField_1′]
Practice ID: [MM_Form_Data name=’username’]
Password: [MM_Form_Data name=’password’]
Email: [MM_Form_Data name=’email’]
Phone: [MM_Form_Data name=’phone’]
Support User Since: [MM_Form_Data name=’registrationDate’]
[MM_Member_Decision status=’pending_cancel’]
Account will cancel on [MM_Member_Data name=’cancellationDate’ dateFormat=’M j, Y’]
[/MM_Member_Decision]
[/MM_Form]