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HTML

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CSS

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JavaScript

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HTML 

              
                .modal
  .side
    .skew
      h3 Google OnHub Shell
      img(src="https://cbwconline.com/IMG/Codepen//OnHub%20Skin.png")
      .btn Total Price: $37.98
  .header
    h1 Enter Payment Details
  .form
    form
      fieldset.number
        label(for='number') Card Number
        input#number(type='num' maxlength='4')
        input(type='num' maxlength='4')
        input(type='num' maxlength='4')
        input(type='num' maxlength='4')
      fieldset.name
        label(for='name') Cardholder Name
        input#name(type='text')
      fieldset.exp
        label(for='exp') Expiration
        select#exp
          option ...
          option Jan
          option Feb
          option Mar
          option Apr
          option May
          option Jun
          option Jul
          option Aug
          option Sep
          option Oct
          option Nov
          option Dec
        select
          option ...
          option 2016
          option 2017
          option 2018
          option 2019
          option 2020
          option 2021
          option 2022
          option 2023
          option 2024
          option 2025
      fieldset.ccv
        label(for='ccv') CCV
        input#ccv(type='num' maxlength='3')
      button(type='button') Confirm And Pay
!

CSS 

              
                *, :before,:after {
  box-sizing: border-box;
  margin: 0;
}

html {
  background: url('https://cbwconline.com/IMG/Codepen/Dark-Grey-Repeating-Background.png');
}

body {
  background: radial-gradient(ellipse at center, rgba(#000, .02) 0%, rgba(#000, .6) 100%);
  height: 100vh;
  overflow: hidden;
  color: #FFF;
  font-family: Roboto;
}

.modal {
  height: 400px;
  width: 650px;
  margin: auto;
  box-shadow: 0 15px 35px rgba(#000, .5);
  position: absolute;
  top: 0; bottom: 0;
  left: 0; right: 0;
  font-size: 0;
}

.side {
  background: linear-gradient(-45deg, #001F60, #009DE0);
  height: 100%;
  width: 100%;
  position: relative;
  .skew {
    background: #F6F6F6;
    height: 110%;
    width: 45%;
    padding: 20px;
    box-shadow: 0 8px 16px rgba(#000, .25);
    position: absolute;
    top: -5%;
    z-index: 5;
    transform: skew(8deg);
    * {
      transform: skew(-8deg);
    }
    h3 {
      color: #474747;
      font:  25px Roboto;
      text-align: center;
    }
    img {
      width: 100%;
      margin: 25px 0;
    }
    .btn {
      background: #474747;
      width: 180px;
      margin: 10px auto;
      padding: 10px 18px;
      font-size: 16px;
      text-align: center;
      border-radius: 3px;
      box-shadow: 0px 3px 10px rgba(#000, .25);
      cursor: default;
    }
  }
}

.header {
  width: 60%;
  position: absolute;
  top: 0;
  right: 0;
  h1 {
    background: linear-gradient(-45deg, #2ed6bc, #01BCE6);
    padding: 10px 25px;
    font: 25px Roboto;
  }
}

.form {
  width: 350px;
  height: 100%;
  position: absolute;
  top: 56px;
  right: 0;
}

input, select, fieldset, button {
  border: none;
  outline: none;
  font: 16px Roboto;
}

fieldset {
  display: block;
}

label {
  display: block;
  color: #01BCE6;
  font: 500 13px Roboto;
}

input, select {
  background: rgba(#FFF, .18);
  padding: 8px 12px;
  margin: 5px 5px 5px 0;
  border-radius: 3px;
  color: #FFF;
  &:nth-last-of-type(1) {
    margin-right: 0;
  }
}

option {
  background: #474747;
}

.number input {
  width: calc(25% - 7px);
}

.name input {
  width: 100%;
}

.exp, .ccv {
  display: inline-block;
}

.exp {
  width: 60%;
  select {
    width: calc(50% - 5px);
  }
}

.ccv {
  width: 40%;
  input {
    width: 100%;
  }
}

button {
  display: block;
  background: linear-gradient(-45deg, #2ed6bc, #01BCE6);
  width: 200px;
  color: white;
  padding: 10px 18px;
  margin: 40px auto;
  font-size: 18px;
  border-radius: 22px;
  box-shadow: 0 5px 10px rgba(#000, .2);
  cursor: pointer;
}
!

JS 

              
                //Daily UI #001 here: https://codepen.io/koenigsegg1/pen/wGoRRR
!
999px

Console