nginx-proxy-manager/frontend/js/app/nginx/ssl-passthrough/form.ejs

<div class="modal-content">
    <div class="modal-header">
        <h5 class="modal-title"><%- i18n('ssl-passthrough-hosts', 'form-title', {id: id}) %></h5>
        <button type="button" class="close cancel" aria-label="Close" data-dismiss="modal">&nbsp;</button>
    </div>
    <div class="modal-body">
        <form>
            <div class="row">
                <div class="col-sm-12 col-md-12">
                    <div class="form-group">
                        <label class="form-label"><%- i18n('all-hosts', 'domain-names') %> <span class="form-required">*</span></label>
                        <input type="text" name="domain_name" class="form-control" id="input-domain" placeholder="example.com" value="<%- domain_name %>" required>
                    </div>
                </div>
                <div class="col-sm-8 col-md-8">
                    <div class="form-group">
                        <label class="form-label"><%- i18n('ssl-passthrough-hosts', 'forwarding-host') %><span class="form-required">*</span></label>
                        <input type="text" name="forwarding_host" class="form-control text-monospace" placeholder="example.com or 10.0.0.1 or 2001:db8:3333:4444:5555:6666:7777:8888" value="<%- forwarding_host %>" autocomplete="off" maxlength="255" required>
                    </div>
                </div>
                <div class="col-sm-4 col-md-4">
                    <div class="form-group">
                        <label class="form-label"><%- i18n('ssl-passthrough-hosts', 'forwarding-port') %> <span class="form-required">*</span></label>
                        <input name="forwarding_port" type="number" class="form-control text-monospace" placeholder="eg: 443" value="<%- forwarding_port %>" required>
                    </div>
                </div>
            </div>
        </form>
    </div>
    <div class="modal-footer">
        <button type="button" class="btn btn-secondary cancel" data-dismiss="modal"><%- i18n('str', 'cancel') %></button>
        <button type="button" class="btn btn-teal save"><%- i18n('str', 'save') %></button>
    </div>
</div>