Medical Needs Form

Medical Needs Form

This page is limited to those who deem themselves to have a necessity for CocoMe products or have been advised by a medical professional. CocoMe LLC assumes no liability or responsibility to determine if there is a medical need for our product as we are not medical professionals.










Before use of CocoMe Products for any type of medical use, We at CocoMe LLC recommends:

  • discussing the options with your doctor and your family
  • discussing the possible outcomes with your doctor and your family
  • reading some educational materials, or doing research online
  • taking a bit of extra time to think about the choices

What do I have to do get assistance?

Please fill out the form on this page. CocoMe LLC will review the information provided. In order to make our decision you may have to

  1. Be interviewed over the phone.
  2. Provide proof of medical conditions. i.e. Doctors note or discharge papers.
  3. Provide a current pay-stub or a monthly bank statement.

We will review your request as soon as possible, you may call us at our toll free number of you like. Please email us or call us if you have not received a response within 5 business days.

How much will the assistance be for.

  • If approved by CocoMe LLC, you will receive a 90 day coupon code for anywhere from 25%, up to 100% off the retail price.
  • Based on income and medical need, you may be required to cover shipping costs up to $5.99 per shipment.
  • The coupon will expire in 90 days. You will need to email us and ask to extend it for 90 more days. You may be required to provide updated financial or medical records.
  • CocoMe LLC reserves the right to share your story for marketing purposes. Our marketing may include a first name and city location, however Full last name, address and all other contact, financial, and medical information provided to us will be kept strictly confidential.
  • CocoMe LLC reserves the right to cancel this medical needs assistance program at any time with 15 days notice via email.
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