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HTML

              
                .container
	.icing
		h2 Your Order
		ul.order
			li
				span.item-count 10
				span.item-name Donuts
				span.item-price $1.99ea
		.total $19.90
					
	.dough
		h2 Payment
		form.form
			.inputs
				.row
					.column.card-group
						label.label(for='card') Card
						input.text-input.card-input#card(placeholder='1234 5678 9012 3456')
				
				.row
					.column.name-group
						label.label(for='name') Name on Card
						input.text-input.name-input#name
					.column.expiry-group
						label.label(for='expiry') Expiry
						input.text-input.expiry-input#expiry(placeholder='dd/yy')
				.row
					.column.cvc-group
						label.label(for='cvc') CVC/Security Code
						input.text-input.cvc-input#cvc
					.column.cvc-help 3-4 digit code. Usually on the back, by the signature.
						
				
			.buttons
				button.order-button Order
              
            
!

CSS

              
                @function yummy-shadow($colour, $bg-colour, $size, $width) {
	$shadow: ();
	$count: round($width/($size * $dot-spacing));
	
	@for $i from 1 through $count - 1 {
		@if $i % 2 == 0 {
			$shadow: append($shadow, 0 $size*$i*$dot-spacing 0 $colour, comma);
		} @else {
			$shadow: append($shadow, $size*$dot-spacing/1.32 $size*$i*$dot-spacing 0 $bg-colour, comma);
		}
	}
	
	@return $shadow;
}

$form-width: 80%;
$form-height: 360px;
$col-icing: #ffb3c9;
$col-icing-fg: white;
$col-bg: #ffe0b1;
$col-fg: #90510E;
$dot-spacing: 0.8;
$dot-size: $form-height/10;
$margin: 20px;

%heading {
	font-family: Arvo, sans-serif;
}

body {
	background-color: #9B7272;
}

.container {
	font-family: PT Sans, sans-serif;
	font-size: 18px;
	
	width: $form-width;
	min-width: 620px;
	max-width: 700px;
	height: $form-height;
	margin: 50px auto;
	
	background: $col-bg;
	border-radius: $dot-size/4;
	overflow: hidden;
}

.icing,
.dough {
	float: left;
	padding: $margin;
	box-sizing: border-box;
	height: 100%;
	display:  flex;
	flex-direction: column;
}

.icing {
	width: 33%;
	position: relative;
	padding-right: $dot-size / 1.5;
	
	background: linear-gradient(to right, darken($col-icing, 6%) 0%, $col-icing 80%);
	color: $col-icing-fg;
	
	&:before {
		content: '';
		width: $dot-size;
		height: $dot-size;
		display: block;
		position: absolute;
		top: -$dot-size/2;
		right: -$dot-size/5;
		z-index: 1;
		
		background: $col-icing;
		border-radius: 50%;
		box-shadow: yummy-shadow($col-icing, $col-bg, $dot-size, $form-height);
	}
}

.dough {
	width: 67%;
	padding-left: $dot-size;
	
	color: $col-fg;
}

.order {
	flex-grow: 1;
	padding: $margin 0;
	margin: $margin 0;
	
	border: 1px solid $col-icing-fg;
	border-color: $col-icing-fg transparent;
	
	li {
		display: flex;
		justify-content: space-between;
	}
}

h2 {
	font-size: 1.2em;
	@extend %heading;
}

.total {
	font-size: 3em;
	@extend %heading;
}

.form {
	display: flex;
	flex-direction: column;
	justify-content: space-between;
	margin-top: $margin;
	flex-grow: 1;
}

.inputs {
	flex-grow: 1;
}

.buttons {
	width: 100%;
}

.row {
	width: 100%;
	display: flex;
	align-items: flex-end;
	margin-bottom: $margin / 2;
}

.column {
	width: 100%;
	
	&:not(:last-child) {
		margin-right: $margin / 2;
	}
}

.label,
.text-input {
	float: left;
	display: block;
	clear: both;
}

.label {
	font-size: 0.8em;
	margin-bottom: 0.2em;
}

.text-input {
	box-sizing: border-box;
	width: 100%;
	padding: $margin / 2;
	
	font-size: 1em;
	font-family: inherit;
	
	background: white;
	border: 1px solid rgba($col-fg, 0.4);
	border-radius: 5px;
	box-shadow: 0 1px 4px rgba(0,0,0,0.1) inset;
}

.cvc-group {
	flex-basis: 140px;
}

.name-group {
	flex-grow: 1;
	flex-basis: 200px;
}

.expiry-group {
	flex-basis: 100px;
}

.cvc-help {
	padding: 4px 0;
	flex-grow: 0;
	width: 200px;
	
	font-size: 0.8em;
	line-height: 1.3em;
	
	opacity: 0.6;
}

.order-button {
	padding: $margin / 2 $margin;
	width: 100%;
	box-sizing: border-box;
	
	font-size: 1em;
	font-family: inherit;
	color: inherit;
	
	background: rgba(255, 255, 255, 0.5);
	border: 1px solid rgba($col-fg, 0.3);
	box-shadow: 0 2px 2px rgba($col-fg, 0.1);
	border-radius: 5px;
	
	transition: background 0.1s, color 0.1s, border-color 0.1s;
	
	&:hover {
		background: darken($col-icing, 10%);
		color: $col-icing-fg;
		border-color: transparent;
	}
}
              
            
!

JS

              
                $(function() {
	$('.card-input').payment('formatCardNumber');
	$('.expiry-input').payment('formatCardExpiry');
	$('.cvc-input').payment('formatCardCVC');

	$('.form').on('submit', function(e) {
		e.preventDefault();
	});
});


              
            
!
999px

Console