oficial/app/resources/views/ventas/reservations/modal/common/form.blade.php

<form class="ui form" id="{{ $prefix }}_reservation_form">
    <input type="hidden" name="{{ $prefix }}_project_id" />
    <div class="three wide required field">
        <label>Fecha</label>
        <div class="ui calendar" id="{{ $prefix }}_date">
            <div class="ui icon input">
                <i class="calendar icon"></i>
                <input type="text" name="{{ $prefix }}_date" />
            </div>
        </div>
    </div>
    <div class="fields">
        <div class="three wide required field">
            <label>RUT</label>
            <div class="ui right labeled input" id="{{ $prefix }}_rut">
                <input type="text" name="{{ $prefix }}_buyer_rut" placeholder="RUT" />
                <div class="ui basic label">-<span id="{{ $prefix }}_digit"></span></div>
            </div>
        </div>
        <div class="field">
            <label></label>
            <div class="ui inline loader" id="{{ $prefix }}_rut_loader"></div>
        </div>
    </div>
    <div class="fields">
        <div class="three wide required field">
            <label>Nombre</label>
            <input type="text" name="{{ $prefix }}_buyer_name" placeholder="Nombre" />
        </div>
        <div class="six wide required field">
            <label>Apellidos</label>
            <input type="text" name="{{ $prefix }}_buyer_last_name" placeholder="Apellido Paterno" />
        </div>
        <div class="six wide field">
            <label></label>
            <input type="text" name="{{ $prefix }}_buyer_last_name2" placeholder="Apellido Materno" />
        </div>
    </div>
    <div class="fields">
        <div class="three wide field">
            <label>Dirección</label>
            <input type="text" name="{{ $prefix }}_buyer_address_street" placeholder="Calle" />
        </div>
        <div class="field">
            <label></label>
            <input type="text" name="{{ $prefix }}_buyer_address_number" placeholder="N°" />
        </div>
        <div class="three wide field">
            <label></label>
            <input type="text" name="{{ $prefix }}_buyer_address_extra" placeholder="Otros Detalles" />
        </div>
    </div>
    <div class="fields">
        <div class="three wide field">
            <label>Comuna</label>
            <div class="ui search selection dropdown" id="{{ $prefix }}_comuna">
                <input type="hidden" name="comuna" />
                <i class="dropdown icon"></i>
                <div class="default text">Comuna</div>
                <div class="menu"></div>
            </div>
        </div>
        <div class="seven wide field">
            <label>Región</label>
            <div class="ui search selection dropdown" id="{{ $prefix }}_region">
                <input type="hidden" name="region" />
                <i class="dropdown icon"></i>
                <div class="default text">Región</div>
                <div class="menu">
                    @foreach($regions as $region)
                        <div class="item" data-value="{{$region->id}}">{{$region->numeral}} - {{$region->descripcion}}</div>
                    @endforeach
                </div>
            </div>
        </div>
    </div>
    <div class="fields">
        <div class="field">
            <label>Teléfono</label>
            <input type="text" name="{{ $prefix }}_buyer_phone" placeholder="Telefono" />
        </div>
        <div class="field">
            <label>Correo</label>
            <div class="ui labeled input">
                <input type="text" name="{{ $prefix }}_buyer_email_name" placeholder="Correo" />
                <div class="ui basic label">@</div>
                <input type="text" name="{{ $prefix }}_buyer_email_domain" placeholder="Dominio" />
            </div>
        </div>
    </div>
    <div class="fields">
        <div class="field">
            <label>Estado Civil</label>
            <input type="text" name="{{ $prefix }}_buyer_marital_status" placeholder="Estado Civil" />
        </div>
        <div class="field">
            <label>Profesión</label>
            <input type="text" name="{{ $prefix }}_buyer_profession" placeholder="Profesión" />
        </div>
        <div class="field">
            <label>Fecha de Nacimiento</label>
            <div class="ui calendar" id="{{ $prefix }}_birthdate">
                <div class="ui icon input">
                    <i class="calendar icon"></i>
                    <input type="text" name="birthdate" />
                </div>
            </div>
        </div>
    </div>
    <div class="six wide field">
        <label>Operador *</label>
        <div class="ui clearable search selection dropdown" id="{{ $prefix }}_broker">
            <input type="hidden" name="{{ $prefix }}_broker" />
            <i class="dropdown icon"></i>
            <div class="default text">Operador</div>
            <div class="menu"></div>
        </div>
    </div>
    <div class="field">
        <label>Agregar Promoción</label>
        <button type="button" class="ui icon button" id="{{ $prefix }}_promotion">
            <i class="plus icon"></i>
        </button>
    </div>
    <div id="{{ $prefix }}_promotions"></div>
    <h4 class="ui dividing header">Unidades <span id="{{ $prefix }}_project_name"></span></h4>
    <div class="fields" id="{{ $prefix }}_unit_buttons"></div>
    <div id="{{ $prefix }}_units"></div>
    <h4 class="ui dividing header">Forma de Pago</h4>
    <div class="fields">
        <div class="field">
            <div class="ui checkbox">
                <input type="checkbox" name="has_pie" id="{{ $prefix }}_has_pie" />
                <label>¿Tiene Pie?</label>
            </div>
        </div>
        <div class="field" id="{{ $prefix }}_pie">
            <label>Pie</label>
            <div class="ui right labeled input">
                <input type="text" name="pie" />
                <div class="ui basic label">UF</div>
            </div>
        </div>
        <div class="field" id="{{ $prefix }}_cuotas">
            <label>Cuotas</label>
            <input type="text" name="cuotas" />
        </div>
    </div>
    <div class="fields">
        <div class="field">
            <div class="ui checkbox">
                <input type="checkbox" name="has_credit" id="{{ $prefix }}_has_credit" />
                <label>¿Tiene Crédito?</label>
            </div>
        </div>
        <div class="field" id="{{ $prefix }}_credit">
            <label>Crédito</label>
            <div class="ui right labeled input">
                <input type="text" name="credit" />
                <div class="ui basic label">UF</div>
            </div>
        </div>
    </div>
</form>